Malaria chemoprophylaxis: what do the travelers choose, and how does pretravel consultation influence their final decision.

Three different drugs (mefloquine, atovaquone/proguanil, doxycycline) are recommended for malaria chemoprophylaxis, each with approximately the same efficacy but various adverse event profiles, regimens, and prices. We investigated which medication the travelers would have chosen on the basis of written evidence-based information and the impact that pretravel consultation had on their decision. A prospective study was performed in a travel clinic and private practice, and 1073 travelers were included; 45% chose mefloquine (Lariam or Mephaquine), 21% atovaquone/proguanil (Malarone), 18% doxycycline (Supracycline), 5% "no prophylaxis," and 11% "do not know." Lariam was principally chosen because of prior experience (38%), Mephaquine because of low price (34%), and doxycycline and Malarone because of the profile of adverse events (55% and 43%, respectively). Based on objective written information, travelers most frequently chose mefloquine for chemoprophylaxis. This suggests that evidence-based information weighs more heavily than negative publicity. Taking into account the perspective of the user should improve appropriateness of the pretravel advice.

Systematic assessment of items influencing Crohn's disease patient's preferences in selecting an anti-TNF agent (Choose TNF trial)

Background and Aims: The three anti-TNF agents infliximab (IFX), adalimumab (ADA) andcertolizumab pegol (CZP) have demonstrated similar efficacy in induction and maintenanceof response and remission in Crohn's disease (CD) treatment. Given the comparability ofthese drugs, patient's preferences may influence the choice of the product. However, dataon patient's preferences for choosing anti-TNF agents are lacking. We therefore aimed toassess the CD patient's appraisal to select the drug of his choice and to identify factorsguiding this decision.Methods: A prospective survey among anti-TNF-naive CD patientswas performed. Patients were provided a description of the three anti-TNF agents focusingon indication, application mode (s.c. vs. i.v.), application time intervals, setting of application(hospital vs. private practice vs. patient's home), average time to apply the medication permonth, typical side effects, and the scientific evidence of efficacy and safety available for everydrug. Patients answered a questionnaire consisting of 17 questions, covering demographic,disease-specific, and medication data.Results: Hundred patients (47f/53m, mean age 45±16years) completed the questionnaire. Disease duration was <1year in 7%, 1-5 years in 31%,and >5 years in 62% of patients. Disease location was ileal in 33%, colonic in 40%, andileocolonic in 27%. Disease phenotype was inflammatory in 68%, stenosing in 29%, andinternally fistulizing in 3% of patients. Additionally, 20% had perianal fistulizing disease.Patients were already treated with the following drugs: mesalamines 61%, budesonide 44%,prednisone 97%, thiopurines 78%, methotrexate 16%. In total, 30% had already heardabout IFX, 20% about ADA, and 11% about CZP. Thirty-six percent voted for treatmentwith ADA, 28% for CZP, and 25% for IFX, whereas 11% were undecided. The followingfactors influenced the patient's decision for choosing a specific anti-TNF drug (severalanswers possible): side effects 76%, physician's recommendation 66%, application mode54%, efficacy experience 52%, time to spend for therapy 27%, patient's recommendations21%, interactions with other medications 12%. The single most important factor for choosinga specific anti-TNF was (1 answer): side effect profile 35%, physician's recommendation22%, efficacy experience 21%, application mode 13%, patient's recommendations 5%, timespent for therapy 3%, interaction with other medications 1%.Conclusions: The majority ofpatients preferred anti-TNF syringes to infusions. The safety profile of the drugs and thephysician's recommendation are major factors influencing the patient's choice for a specificanti-TNF drug. Patient's issues about safety and lifestyle habits should be taken into accountwhen prescribing specific anti-TNF formulations.

Shared decision making development in Switzerland: room for improvement!

In Switzerland there is a strong movement at a national policy level towards strengthening patient rights and patient involvement in health care decisions. Yet, there is no national programme promoting shared decision making. First decision support tools (prenatal diagnosis and screening) for the counselling process have been developed and implemented. Although Swiss doctors acknowledge that shared decision making is important, hierarchical structures and asymmetric physician-patient relationships are still prevailing. The last years have seen some promising activities regarding the training of medical students and the development of patient support programmes. Swiss direct democracy and the habit of consensual decision making and citizen involvement in general may provide a fertile ground for SDM development in the primary care setting.

Production Flow Analysis - cases from manufacturing and service industry

Production flow analysis (PFA) is a well-established methodology used for transforming traditional functional layout into product-oriented layout. The method uses part routings to find natural clusters of workstations forming production cells able to complete parts and components swiftly with simplified material flow. Once implemented, the scheduling system is based on period batch control aiming to establish fixed planning, production and delivery cycles for the whole production unit. PFA is traditionally applied to job-shops with functional layouts, and after reorganization within groups lead times reduce, quality improves and motivation among personnel improves. Several papers have documented this, yet no research has studied its application to service operations management. This paper aims to show that PFA can well be applied not only to job-shop and assembly operations, but also to back-office and service processes with real cases. The cases clearly show that PFA reduces non-value adding operations, introduces flow by evening out bottlenecks and diminishes process variability, all of which contribute to efficient operations management.

Representational pseudoneglect and reference points both influence geographic location estimates

Our mental representation of the world is far from objective. For example, western Canadians estimate the locations of North American cities to be too far to the west. This bias could be due to a reference point effect, in which people estimate more space between places close to them than far from them, or to representational pseudoneglect, in which neurologically intact individuals favor the left side of space when asked to image a scene.We tested whether either or both of these biases influence the geographic world representations of neurologically intact young adults from Edmonton and Ottawa, which are in western and eastern Canada, respectively. Individuals were asked to locate NorthAmerican cities on a two-dimensional grid. Both groups revealed effects of representational pseudoneglect in this novel paradigm, but they also each exhibited reference point effects. These results inform theories in both cognitive psychology and neuroscience.

The InterActive Choice Aid: A new approach to supporting online consumer decision making

Interactive Choice Aid (ICA) is a decision aid, introduced in this paper, that systematically assists consumers with online purchase decisions. ICA integrates aspects from prescriptive decision theory, insights from descriptive decision research, and practical considerations; thereby combining pre-existing best practices with novel features. Instead of imposing an objectively ideal but unnatural decision procedure on the user, ICA assists the natural process of human decision-making by providing explicit support for the execution of the user's decision strategies. The application contains an innovative feature for in-depth comparisons of alternatives through which users' importance ratings are elicited interactively and in a playful way. The usability and general acceptance of the choice aid was studied; results show that ICA is a promising contribution and provides insights that may further improve its usability.

Toxic substances in blood: an analysis of current recommendations under a Bayesian (decision) approach

This article extends existing discussion in literature on probabilistic inference and decision making with respect to continuous hypotheses that are prevalent in forensic toxicology. As a main aim, this research investigates the properties of a widely followed approach for quantifying the level of toxic substances in blood samples, and to compare this procedure with a Bayesian probabilistic approach. As an example, attention is confined to the presence of toxic substances, such as THC, in blood from car drivers. In this context, the interpretation of results from laboratory analyses needs to take into account legal requirements for establishing the 'presence' of target substances in blood. In a first part, the performance of the proposed Bayesian model for the estimation of an unknown parameter (here, the amount of a toxic substance) is illustrated and compared with the currently used method. The model is then used in a second part to approach-in a rational way-the decision component of the problem, that is judicial questions of the kind 'Is the quantity of THC measured in the blood over the legal threshold of 1.5 μg/l?'. This is pointed out through a practical example.

Altered decision-making in multiple sclerosis: a sign of impaired emotional reactivity?

We assessed decision-making capacity and emotional reactivity in 20 patients with multiple sclerosis (MS) and in 16 healthy subjects using the Gambling Task (GT), a model of real-life decision making, and the skin conductance response (SCR). Demographic, neurological, affective, and cognitive parameters were analyzed in MS patients for their effect on decision-making performance. MS patients persisted longer (slope, -3.6%) than the comparison group (slope, -6.4%) in making disadvantageous choices as the GT progressed (p < 0.001), suggesting significant slower learning in MS. Patients with higher Expanded Disability Status Scale scores (EDSS >2.0) showed a different pattern of impairment in the learning process compared with patients with lower functional impairment (EDSS </=2.0). This slower learning was associated with impaired emotional reactivity (anticipatory SCR 3.9 vs 6.1 microSiemens [microS] for patients vs the comparison group, p < 0.0001; post-choice SCR 3.9 vs 6.2 microS, p < 0.0001), but not with executive dysfunction. Impaired emotional dimensions of behavior (assessed using the Dysexecutive Questionnaire, p < 0.002) also correlated with slower learning. Given the considerable consequences that impaired decision making can have on daily life, we suggest that this factor may contribute to handicap and altered quality of life secondary to MS and is dependent on emotional experience. Ann Neurol 2004.