Strategy selection during exploratory behavior: sex differences

This study was designed to assess sex-related differences in the selection of an appropriate strategy when facing novelty. A simple visuo-spatial task was used to investigate exploratory behavior as a specific response to novelty. The exploration task was followed by a visual discrimination task, and the responses were analyzed using signal detection theory. During exploration women selected a local searching strategy in which the metric distance between what is already known and what is unknown was reduced, whereas men adopted a global strategy based on an approximately uniform distribution of choices. Women's exploratory behavior gives rise to a notion of a secure base warranting a sense of safety while men's behavior does not appear to be influenced by risk. This sex-related difference was interpreted as a difference in beliefs concerning the likelihood of uncertain events influencing risk evaluation. Keywords: exploration, spontaneous strategies, sex differences, decision-making.

An empirical hierarchical Bayesian unification of occupational exposure assessment methods.

In occupational exposure assessment of airborne contaminants, exposure levels can either be estimated through repeated measurements of the pollutant concentration in air, expert judgment or through exposure models that use information on the conditions of exposure as input. In this report, we propose an empirical hierarchical Bayesian model to unify these approaches. Prior to any measurement, the hygienist conducts an assessment to generate prior distributions of exposure determinants. Monte-Carlo samples from these distributions feed two level-2 models: a physical, two-compartment model, and a non-parametric, neural network model trained with existing exposure data. The outputs of these two models are weighted according to the expert's assessment of their relevance to yield predictive distributions of the long-term geometric mean and geometric standard deviation of the worker's exposure profile (level-1 model). Bayesian inferences are then drawn iteratively from subsequent measurements of worker exposure. Any traditional decision strategy based on a comparison with occupational exposure limits (e.g. mean exposure, exceedance strategies) can then be applied. Data on 82 workers exposed to 18 contaminants in 14 companies were used to validate the model with cross-validation techniques. A user-friendly program running the model is available upon request.

Physicians' estimates of the 10 year cardiovascular risk in hypertensive patients: an evaluation in primary care physicians in training.

To evaluate how young physicians in training perceive their patients' cardiovascular risk based on the medical charts and their clinical judgment. Cross sectional observational study. University outpatient clinic, Lausanne, Switzerland. Two hundred hypertensive patients and 50 non-hypertensive patients with at least one cardiovascular risk factor. Comparison of the absolute 10-year cardiovascular risk calculated by a computer program based on the Framingham score and adapted for physicians by the WHO/ISH with the perceived risk as assessed clinically by the physicians. Physicians underestimated the 10-year cardiovascular risk of their patients compared to that calculated with the Framingham score. Concordance between methods was 39% for hypertensive patients and 30% for non-hypertensive patients. Underestimation of cardiovascular risks for hypertensive patients was related to the fact they had a stabilized systolic blood pressure under 140 mm Hg (OR = 2.1 [1.1; 4.1]). These data show that young physicians in training often have an incorrect perception of the cardiovascular risk of their patients with a tendency to underestimate the risk. However, the calculated risk could also be slightly overestimated when applying the Framingham Heart Study model to a Swiss population. To implement a systematic evaluation of risk factors in primary care a greater emphasis should be placed on the teaching of cardiovascular risk evaluation and on the implementation of quality improvement programs.

Addressing ethical dilemmas in the clinical care of adolescents: an international view.

This chapter reviews some basic concepts underlying ethical issues in adolescence and provides a step-by-step procedure to address ethical dilemmas involving minor adolescents, based on a deliberative approach. "Deliberation" with the patient, along with involving the opinion of relevant stakeholders if possible, allows for a careful, multidisciplinary examination of all options, the medical and psychosocial consequences, and the moral values stressed by each option. Although the final decision regarding which ethical option should be chosen usually belongs to the health care providers and his or her patient, the deliberative approach provides the ingredients for sound, unbiased decision-making.

Le trouble de l'adaptation, un diagnostic anodin ? : une étude comparative avec le trouble dépressif majeur

Résumé Le trouble de l'adaptation est un diagnostic très fréquent, mais étonnamment peu étudié et controversé. Il est, selon les études, considéré comme une forme mineure d'un trouble psychiatrique spécifique, comme une fragilité psychologique révélée par un événement stressant pour le sujet ou encore comme une forme précoce annonçant un trouble psychiatrique majeur. Ces trois points de vue ramènent en fait tous à la question de fond concernant son étiologie. L'objectif de cette étude est de montrer si le trouble de l'adaptation est un diagnostic clairement différencié dont l'existence est justifiée. Afin de tenter de répondre à cette question, il nous est apparu intéressant de comparer cette catégorie diagnostique à une autre catégorie diagnostique psychiatrique importante, le trouble dépressif majeur. Dans cette étude rétrospective nous avons sélectionné tous les patients avec un diagnostic de trouble de l'adaptation ou un trouble dépressif majeur parmi les patients hospitalisés à l'hôpital psychiatrique de Malévoz en Valais en 1993 (580). Elle est basée sur des diagnostics cliniques. Nous avons comparé leurs données socio-démographiques (âge, sexe, nationalité, état civil, activité professionnelle), leurs antécédents psychiatriques (hospitalisations antérieures, suivi psychiatrique ambulatoire, antécédents de tentamen), leurs hospitalisations ultérieures dans les 5 ans, leur hospitalisation actuelle (durée, tentamens, comorbidité) et les traitements médicamenteux prescrits (leur nombre et leur classe). Notre étude met en évidence certaines distinctions entre le trouble de l'adaptation et le trouble dépressif majeur: les patients souffrant de trouble de l'adaptation diffèrent des troubles dépressifs majeurs par le fait qu'ils sont plus fréquemment des hommes, célibataires et plus jeunes que ceux souffrant de trouble dépressif majeur; leur durée d'hospitalisation est plus courte, leur évolution entre les hospitalisations est meilleure et ils reçoivent moins de psychotropes. Nous ne pouvons cependant pas conclure à une distinction claire de ces deux catégories diagnostiques, ni que le trouble de l'adaptation n'est pas simplement lié à une moindre gravité. Nos résultats confirment par contre que ce diagnostic n'est pas non plus un diagnostic anodin (nombre élevé d'antécédents psychiatriques, de tentamens, d'hospitalisations psychiatriques ultérieures, importance des comorbidités de même que la lourdeur des traitements psychotropes prescrits (notamment la fréquence des neuroleptiques). A notre avis, les trois hypothèses étiologiques (forme mineure, trouble précoce ou fragilité psychologique spécifique révélée par un événement stressant) qui ont été évoquées peuvent être considérées comme plausibles suivant le point de vue que l'on choisit. Le diagnostic de trouble de l'adaptation révèle une des limitations de l'approche du DSM-Ill-R qui se veut athéorique. Le fait que dans sa définition même, le DSM-111-R évoque "qu'il faut souvent se référer au seul jugement clinique" le montre bien, un tel diagnostic renvoie inévitablement à une référence psychopathologique. Nous pensons qu'il est illusoire de vouloir se passer d'une telle référence qui elle seule permet d'appréhender justement la portée symbolique d'un événement donné pour un individu. Summary In this retrospective study we selected all the patients with a diagnosis of adjustment disorder (77) or major depressive disorder (125) among the patients hospitalised in the psychiatric hospital of Malevoz in Valais during the year 1993 (580). It is based on clinical diagnosis. Their social and demographic characteristics (age, sex, nationality, marital status, professional activity), their past psychiatric history (earlier psychiatric hospitalisations, ambulatory treatment and attempted suicide), their hospitalisations during the next 5 years, their index hospitalisation (length, attempted suicide, comorbidity) and their drug treatment (number and class of prescribed drugs) were compared. This survey confirms certain differences be-tween adjustment disorder and major depression disorder: patients suffering from adjustment disorder were more often men, not married, younger than those suffering from major depression; their hospitalisations were shorter with a better evolution between hospitalisations and they received less medication. However, the study does not allow to clearly distinguish between the two diagnoses or to conclude that adjustment disorder is not only a minor form of a specific psychiatric disorder. Yet it confirms that adjustment disorder is not a light diagnosis (importance of the psychiatric past, high number of past attempted suicides, rehospitalisations, number of comorbid disorders and weight of the prescribed psychotropic treatments among which neuroleptics were frequent). The three aetiological hypotheses that have been proposed (minor form of a specific disorder, specific psychological vulnerability revealed by a stress factor or precursor manifestation of a major psychiatric disorder) can still be considered as plausible. The diagnosis of adjustment disorder points to methodological limitations of the atheoretical approach of the DSM-III-R. The fact that, in its DSM-III-R definition, it is stated that the diagnosis of adjustment disorder has often to be based only on clinical judgment shows very well that such a diagnosis inevitably refers to a psychopathological theory. Indeed, the authors consider an approach without such a reference as difficult, a reference which remains the only way to appreciate accurately the symbolic weight of a given event for an individual person.

Appropriateness of colonoscopy in Europe (EPAGE II): presentation of methodology, general results, and analysis of complications.

BACKGROUND AND STUDY AIMS: Appropriate use of colonoscopy is a key component of quality management in gastrointestinal endoscopy. In an update of a 1998 publication, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE II) defined appropriateness criteria for various colonoscopy indications. This introductory paper therefore deals with methodology, general appropriateness, and a review of colonoscopy complications. METHODS:The RAND/UCLA Appropriateness Method was used to evaluate the appropriateness of various diagnostic colonoscopy indications, with 14 multidisciplinary experts using a scale from 1 (extremely inappropriate) to 9 (extremely appropriate). Evidence reported in a comprehensive updated literature review was used for these decisions. Consolidation of the ratings into three appropriateness categories (appropriate, uncertain, inappropriate) was based on the median and the heterogeneity of the votes. The experts then met to discuss areas of disagreement in the light of existing evidence, followed by a second rating round, with a subsequent third voting round on necessity criteria, using much more stringent criteria (i. e. colonoscopy is deemed mandatory). RESULTS: Overall, 463 indications were rated, with 55 %, 16 % and 29 % of them being judged appropriate, uncertain and inappropriate, respectively. Perforation and hemorrhage rates, as reported in 39 studies, were in general < 0.1 % and < 0.3 %, respectively CONCLUSIONS: The updated EPAGE II criteria constitute an aid to clinical decision-making but should in no way replace individual judgment. Detailed panel results are freely available on the internet (www.epage.ch) and will thus constitute a reference source of information for clinicians.

Postoperative management of adult central neurosurgical patients: systemic and neuro-monitoring.

Postoperative neurosurgical patients are at risk of developing complications. Systemic and neuro-monitoring are used to identify patients who deteriorate in order to treat the underlying cause and minimize the impact on outcome. Hypotension and hypoxia are likely to be the most frequent insults and can be detected easily with blood pressure monitoring and pulse oximetry. Repeated clinical examination, however, is probably the most important monitor in the postoperative setting. Clinical scores such as the Glasgow Coma Score and the more recently introduced FOUR Score are important tools to standardize the clinical assessment. Intracranial pressure monitoring, cerebral blood flow monitoring, electroencephalography, and brain imaging are often used postoperatively. Despite the numerous publications on this topic only few studies address the impact of postoperative monitoring on outcome. Accordingly, in most patients the decision on which monitors are to be used must be based on the patient's presentation and clinical judgment.

Recognition judgments and the performance of the recognition heuristic depend on the size of the reference class

In a series of three experiments, participants made inferences about which one of a pair of two objects scored higher on a criterion. The first experiment was designed to contrast the prediction of Probabilistic Mental Model theory (Gigerenzer, Hoffrage, & Kleinbölting, 1991) concerning sampling procedure with the hard-easy effect. The experiment failed to support the theory's prediction that a particular pair of randomly sampled item sets would differ in percentage correct; but the observation that German participants performed practically as well on comparisons between U.S. cities (many of which they did not even recognize) than on comparisons between German cities (about which they knew much more) ultimately led to the formulation of the recognition heuristic. Experiment 2 was a second, this time successful, attempt to unconfound item difficulty and sampling procedure. In Experiment 3, participants' knowledge and recognition of each city was elicited, and how often this could be used to make an inference was manipulated. Choices were consistent with the recognition heuristic in about 80% of the cases when it discriminated and people had no additional knowledge about the recognized city (and in about 90% when they had such knowledge). The frequency with which the heuristic could be used affected the percentage correct, mean confidence, and overconfidence as predicted. The size of the reference class, which was also manipulated, modified these effects in meaningful and theoretically important ways.

When performance-approach goals predict academic achievement and when they do not: A social value approach

Research on achievement goal promotion at University has shown that performance-approach goals are perceived as a means to succeed at University (high social utility) but are not appreciated (low social desirability). We argue that such a paradox could explain why research has detected that performance-approach goals consistently predict academic grades. First-year psychology students answered a performance-approach goal scale with standard, social desirability and social utility instructions. Participants' grades were recorded at the end of the semester. Results showed that the relationship between performance-approach goals and grades was inhibited by the increase of these goals' social desirability and facilitated by the increase of their social utility, revealing that the predictive validity of performance-approach goals depend on social value.

Le partage des responsabilités dans l'espace Dublin, entre confiance mutuelle et sécurité des demandeurs d'asile

On 21 January 2011, the Grand Chamber of the European Court of Human Rights delivered its judgment in the case of MSS v. Belgium and Greece. This judgment puts into question the practices followed by many national authorities in the implementation of the Dublin system. Particularly noteworthy are the effects on the "safety presumption" that Member States accord to each other in the field of asylum. The authors explore the implications of the MSS decision, first, in regard of the evidentiary requirements imposed on asylum seekers to rebut the safety presumption. They come to the conclusion that through the decision, a real paradigm-shift has taken place - from the theoretical to the actual supremacy of the non-refoulement principle in Dublin matters. This is also true in light of the increased requirements imposed by the Court as regards the scope and depth of judicial review on transfer decisions. Moreover, the MSS judgment could give new impetus to the stalled reform process concerning the Dublin Regulation. Indeed, the Court's decision seems to enshrine in positive ECHR law the most progressive elements of the Commission's proposal, including procedural guarantees and, de facto, the mechanism for the temporary suspension of transfers to member states not offering adequate protection.

Influence of the morphology of the dural sac on surgical decision making in lumbar spinal stenosis

Introduction: Surgical decision making in lumbar spinal stenosis (LSS) takes into account primarily clinical symptoms as well as concordant radiological findings. We hypothesized that a wide variation of operative threshold would be found in particular as far as judgment of severity of radiological stenosis is concerned. Patients and methods: The number of surgeons who would proceed to decompression was studied relative to the perceived severity of radiological stenosis based either on measurements of dural sac cross sectional area (DSCA) or on the recently described morphological grading as seen on axial T2 MRI images. A link to an electronic survey page with a set of ten axial T2 MRI images taken from ten patients with either low back pain or LSS were sent to members of three national or international spine societies. Those 10 images were randomly presented initially and re-shuffled on a second page including this time DSCA measurements in mm2, ranging from 14 to 226 mm2, giving a total of 20 images to appraise. Morphological grades were ranging from grade A to D. Surgeons were asked if they would consider decompression given the radiological appearance of stenosis and that symptoms of neurological claudication were severe in patients who were otherwise fit for surgery. Fisher's exact test was performed following dichotomization of data when appropriate. Results: A total of 142 spine surgeons (113 orthopedic spine surgeons, 29 neurosurgeons) responded from 25 countries. A substantial agreement was observed in operating patients with severe (grade C) or extreme (grade D) stenosis as defined by the morphological grade compared to lesser stenosis (A&B) grades (p<0.0001). Decision to operate was not dependent on number of years in practice, medical density in practicing country or specialty although more neurosurgeons would operate on grade C stenosis (p<0.005). Disclosing the DSCA measurement did not alter the decision to operate. Although 20 surgeons only had prior knowledge of the description of the morphological grading, their responses showed no statistically significant difference with those of the remaining 122 physicians. Conclusions: This study showed that surgeons across borders are less influenced by DSCA in their decision making than by the morphological appearance of the dural sac. Classifying LSS according to morphology rather than surface measurements appears to be consistent with current clinical practice.

Edulcorants: entre mythe et réalité [Sweeteners: between myth and reality]

As the prevalence of obesity and diabetes are continually increasing, the use of "false sugars" otherwise known as sweeteners, and their associated health issues are being more and more discussed. A higher sugared power, less calories as well as a moderated or non-existent effect on blood sugar would lead to believe that sweeteners are helpful. However, we CANNOT say that they are THE solution as they can contain calories, may have some undesired effects, and moreover they ease the conscience without actually allowing a weight loss with their sole use. They are to be used with judgment, wittingly and especially when comparing sweetened products. The sweetener myth is often far from reality. It is therefore important to give our patients the means to analyze their dietary intake with regard to their sweeteners ingestion.