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.

The journey to concordance for patients with hypertension: a qualitative study in primary care

Objective: We aimed to explore, using qualitative methods, the perspectives of patients with hypertension on issues relating to concordance in prescribing.

Method: This study took place in NHS general practices in Northern Ireland. A purposeful sample of patients who had been prescribed anti-hypertensive medication for at least one year were invited to participate in focus groups or semi-structured interviews; data were analysed using constant comparison.

Main outcome measures: The perspectives of patients with hypertension on issues relating to concordance in prescribing.

Results: Twenty-five individuals participated in five focus groups; two participated in semi-structured interviews. Participants felt they could make valuable contributions to consultations regarding their management. They were prepared to negotiate with GPs regarding their medication, but most deferred to their doctor’s advice, perceiving doctors’ attitudes and time constraints as barriers to their greater involvement in concordant decision-making. They had concerns about taking anti-hypertensive drugs, were aware of lifestyle influences on hypertension and reported using personal strategies to facilitate adherence and reduce the need to take medication.

Conclusions: Participants indicated a willingness to be?involved in concordance in prescribing anti- hypertensive medication but needed health professionals to address their concerns and confusion about the nature of hypertension. These findings suggest that there is a need for doctors and other healthcare professionals with responsibility for prescribing to develop skills specifically to explore the beliefs and views underlying an individual’s medication use. Such skills may need to be developed through specific training programmes at both undergraduate and postgraduate level.

Selection with melphalan or paclitaxel (Taxol) yields variants with different patterns of multidrug resistance, integrin expression and in vitro invasiveness

A melphalan-resistant variant (Roswell Park Memorial Institute (RPMI)-2650M1) and a paclitaxel-resistant variant (RPMI-1650Tx) of the drug-sensitive human nasal carcinoma cell line, RPMI-2650. were established. The multidrug resistance (MDR) phenotype in the RPMI-2650Tx appeared to be P-glycoprotein (PgP)-mediated. Overexpression of multidrug resistant protein (MRP) family members was observed in the RPMI-2650M1 cells, which were also much more invasive in vitro than the parental cell line or the paclitaxel-resistant variant. Increased expression of alpha (2), alpha (5), alpha (6), beta (1) and beta (4) integrin subunits, decreased expression of alpha (4) integrin subunit, stronger adhesion to collagen type IV, laminin, fibronectin and matrigel, increased expression of MMP-2 and MMP-9 and significant motility compared with the parental cells were observed, along with a high invasiveness in the RPMI-7650M1 cells. Decreased expression of the alpha (2) integrin subunit, decreased attachment to collagen type IV, absence of cytokeratin 18 expression, no detectable expression of gelatin-degrading proteases and poor motility may be associated with the non-invasiveness of the RPMI-2650Tx variant. These results suggest that melphalan exposure can result in not only a MDR phenotype. but could also make cancer cells more invasive, whereas paclitaxel exposure resulted in MDR without increasing the in vitro invasiveness in the RPMI-2650 cells. (C) 2001 Elsevier Science Ltd. All rights reserved.

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.

Improving the utilisation of University teaching space

There is a perception that teaching space in universities is a rather scarce resource. However, some studies have revealed that in many institutions it is actually chronically under-used. Often, rooms are occupied only half the time, and even when in use they are often only half full. This is usually measured by the “utilisation” which is basically the percentage of available ’seat-hours’ that are employed. In real institutions, this utilisation can often takes values as low as 20-40%. One consequence of such low utilisation is that space managers are under pressure to make a more efficient use of the available teaching space. However, better management is hampered because there does not appear to be a good understanding within space management (near-term planning) of why this happens. Nor, a good basis within space planning (long-term planning) of how best to accommodate the expected low utilisations. This motivates our two main goals: (i) To understand the factors that drive down utilisations, (ii) To set up methods to provide better space planning. Here, we provide quantitative evidence that constraints arising from timetabling and location requirements easily have the potential to explain the low utilisations seen in reality. Furthermore, on considering the decision question “Can this given set of courses all be allocated in the available teaching space?” we find that the answer depends on the associated utilisation in a way that exhibits threshold behaviour: There is a sharp division between regions in which the answer is “almost always yes” and those of “almost always no”. Our work suggests that progress in space management and planning will arise from an integrated approach; combining purely space issues with restrictions representing an aggregated or abstracted version of key constraints such as timetabling or location, and

Exile or emigrant? Female ex-prisoners who left Ireland 1850-1921

In the popular mind, the concept of 'emigration' usually refers to people voluntarily leaving one country to go to another in search of a new and better life. It presupposes some degree of choice, although it is accepted that for many emigrants, such as those who left Ireland during the nineteenth century, there were few incentives to stay at home. Current scholarship on voluntary and forced movements of people demonstrates that the distinction between the categories of 'voluntary emigrant' and 'forced exile' is often blurred. Orm Overland's study of refugee communities in the United States highlights the fact that, although the differences between the 'emigrant' and the 'exile' may be clear in extreme cases, this is not always true, as there may be 'pressing political or economic reasons behind a decision to emigrate'. Migration scholars Jan Lucassen and Leo Lucassen also question the adequacy of conceptual models of migration based on what Lindsay Proudfoot and Dianne Hall refer to as the 'straightforward binarism between free and unfree emigration'. The questions raised by these scholars are very relevant to the study of Irish people who left their country during the second half of the nineteenth century immediately after they had been discharged from prison or from Dundrum. Their stories are discussed here against a background of substantial scholarship on emigration from Ireland and on the criminal justice system within Ireland. According to David Fitzpatrick, at least eight million men, women and children emigrated from Ireland between 1801 and 1921. This large-scale movement of people was generally characterised by the voluntary emigration of individuals who funded their own passages. However, it also included schemes of assisted emigration, funded variously by governments, landlords, the poor law authorities, earlier emigrants, and philanthropists. In addition, it included people who were transported from Ireland by means of the criminal justice system a practice that had originated in the seventeenth century. What is less well known is that after the end of transportation from Ireland to eastern Australia in 1853, to Bermuda in 1863 and to Western Australia in 1868, Irish convicts continued to be channelled towards emigration by being offered early release if they agreed to leave Ireland. These people, and especially the women among them, are the subject of this article.

Extending BPM Environments of Your Choice with Performance Related Decision Support

What-if Simulations have been identified as one solution for business performance related decision support. Such support is especially useful in cases where it can be automatically generated out of Business Process Management (BPM) Environments from the existing business process models and performance parameters monitored from the executed business process instances. Currently, some of the available BPM Environments offer basic-level performance prediction capabilities. However, these functionalities are normally too limited to be generally useful for performance related decision support at business process level. In this paper, an approach is presented which allows the non-intrusive integration of sophisticated tooling for what-if simulations, analytic performance prediction tools process optimizations or a combination Of Such solutions into already existing BPM environments. The approach abstracts from process modelling techniques which enable automatic decision support spanning processes across numerous BPM Environments. For instance, this enables end-to-end decision support for composite processes modelled with the Business Process Modelling Notation (BPMN) on top of existing Enterprise Resource Planning (ERP) processes modelled with proprietary languages.

El significado de la prosopopeya de las Leyes en el "Critón" de Platon

El objeto de este trabajo es realizar un estudio iusfilosófico sobre la aparición de las Leyes (nómoi) personificadas de Atenas en el Critón de Platón. La prosopopeya de las Leyes resulta ser un aspecto central para poder comprender la obra, ya que éstas entablan un diálogo imaginario con Sócrates en el cual instalan diversos argumentos filosóficos para fundamentar la autoridad de la pólis. A los fines de identificar el valor argumentativo de este recurso en la obra, analizaré el significado del nómos en la Atenas del siglo V a. C. y la naturaleza de las Leyes en el contexto general del diálogo. Se busca demostrar la importancia que tienen aquéllas para explicar la decisión de Sócrates de beber la cicuta.

So mechanical or routine: The not original in Feist

The United States Supreme Court case of 1991, Feist Publications, Inc. v. Rural Tel. Service Co., continues to be highly significant for property in data and databases, but remains poorly understood. The approach taken in this article contrasts with previous studies. It focuses upon the “not original” rather than the original. The delineation of the absence of a modicum of creativity in selection, coordination, and arrangement of data as a component of the not original forms a pivotal point in the Supreme Court decision. The author also aims at elucidation rather than critique, using close textual exegesis of the Supreme Court decision. The results of the exegesis are translated into a more formal logical form to enhance clarity and rigor.


The insufficiently creative is initially characterized as “so mechanical or routine.” Mechanical and routine are understood in their ordinary discourse senses, as a conjunction or as connected by AND, and as the central clause. Subsequent clauses amplify the senses of mechanical and routine without disturbing their conjunction.


The delineation of the absence of a modicum of creativity can be correlated with classic conceptions of computability. The insufficiently creative can then be understood as a routine selection, coordination, or arrangement produced by an automatic mechanical procedure or algorithm. An understanding of a modicum of creativity and of copyright law is also indicated.


The value of the exegesis and interpretation is identified as its final simplicity, clarity, comprehensiveness, and potential practical utility.

Optimum decision delay of the finite-length DFE

This letter investigates the optimum decision delay and tap-length of the finite-length decision feedback equalizer. First we show that, if the feedback filter (FBF) length N-b is equal to or larger than the channel memory upsilon and the decision delay Delta is smaller than the feedforward filter (FFF) length N-f, then only the first Delta + 1 elements of the FFF can be nonzero. Based on this result we prove that the maximum effective FBF length is equal to the channel memory upsilon, and if N-b greater than or equal to upsilon and N-f is long enough, the optimum decision delay that minimizes the MMSE is N-f - 1.

Decision making by senior social workers at point of first referral

In the United Kingdom there has been difficulty in implementing the family support provisions contained in the 1989 Children Act, largely because of continued emphasis on child protection activity by local authorities. There is an observable international tendency for child-care referrals to receive investigative response, resulting in families being traumatized and children's needs left unmet. There has been a lack of research into how child-care referrals are initially categorized by senior social workers. This paper reports on research undertaken in two Health and Social Services Trusts within Northern Ireland to ascertain if it might be possible to treat more initial referrals as 'child-care problem enquiries' as opposed to 'child protection investigations'. Results demonstrate that, while such potential may exist, a preoccupation with the management of risk could lead to the development of child-care problems receiving quasi-child protection responses. Consequently, changes in initial decision making may not have the full intended effects in terms of the organizational release of resources for family support or a lessening of the traumatic impact upon families.

Alternative antecedents, probabilities, and the suppression of fallacies in Wason's selection task

Three experiments examined the influence of a second rule on the pattern of card selections on Wason's selection task. In Experiment 1 participants received a version of the task with a single test rule or one of two versions of the task with the same original test rule together with a second rule. The probability of q was manipulated in the two-rules conditions by varying the size of the antecedent set in the second rule. The results showed a significant suppression of q card and not-p card selections in the alternative-rule conditions, but no difference as a function of antecedent set size. In Experiment 2 the size of the antecendent set in the two-rules conditions was manipulated using the context of a computer printing double-sided cards. The results showed a significant reduction of q card selections in the two-rules conditions, but no effect of p set size. In Experiment 3 the scenario accompanying the rule was manipulated, and it specified a single alternative antecedent or a number of alternative antecedents. The q card selection rates were not affected by the scenario manipulation but again were suppressed by the presence of a second rule. Our results suggest that people make inferences about the unseen side of the cards when engaging with the task and that these inferences are systematically influenced by the presence of a second rule, but are not influenced by the probabilistic characteristics of this rule. These findings are discussed in the context of decision theoretic views of selection task performance (Oaksford Chater, 1994).

Gender and Welfare States in East Asia: Confucianism or Equality?

Is a Confucian cultural climate hostile to gender equality in families and public decision-making? What is the impact of gender equality legislation in East Asia? Approaches to these welfare regimes have ignored gender, while gendered accounts of welfare have neglected East Asia. Comparisons with Western welfare states show strong economies with life expectancy in Japan and South Korea above those of Western social democracies but in contrast there are extremely large gender gaps in employment, earning, unpaid work and parliamentary representation and conjoined with this low fertility rates and and minimal public social spending on childcare and early education.

In this volume, contributors address questions about gender equality in a Confucian context across a wide and varied social policy landscape, from Korea and Taiwan, where Confucian culture is deeply embedded, through China, with its transformations from Confucianism to communism and back, to the mixed cultural environments of Hong Kong and Japan. Overall, the collections asks: Has East Asia's rapid economic transformation been accompanied by social and cultural transformation?

Professional perspectives on decision making about the long-term care of older people

With the increasing pressure on social and health care resources, professionals have to be more explicit in their decision making regarding the long-term care of older people. This grounded theory study used 19 focus groups and nine semi-structured interviews (99 staff in total) to explore professional perspectives on this decision making. Focus group participants and interviewees comprised care managers, social workers, consultant geriatricians, general medical practitioners, community nurses, home care managers, occupational therapists and hospital discharge support staff. The emerging themes spanned context, clients, families and services. Decisions were often prompted by a crisis, hindering professionals seeking to make a measured assessment. Fear of burglary and assault, and the willingness and availability of family to help were major factors in decisions about living at home. Service availability in terms of public funding for community care, the availability of home care workers and workload pressures on primary care services influenced decision 'thresholds' regarding admission to institutional care. Assessment tools designed to assist decision making about the long-term care of older people need to take into account the critical aspects of individual fears and motivation, family support and the availability of publicly funded services as well as functional and medical needs.

Explicit argumentation as a supervisory tool for decision making in child protection cases involving human rights issues

This paper addresses the problems often faced by social workers and their supervisors in decision making where human rights considerations and child protection concerns collide. High profile court cases in the United Kingdom and Europe have consistently called for social workers to convey more clarity when justifying their reasons for interfering with human rights in child protection cases. The themes emerging from these case law decisions imply that social workers need to be better at giving reasons and evidence in more explicit ways to support any actions they propose which cause interference with Convention Rights. Toulmin (1958, 1985) offers a structured approach to argumentation which may have relevance to the supervision of child protection cases when social workers and managers are required to balance these human rights considerations. One of the key challenges in this balancing act is the need for decision makers to feel confident that any interventions resulting in the interference of human rights are both justified and proportionate. Toulmin’s work has already been shown to have relevance for assisting social workers navigate pathways through cases involving competing ethical and moral demands (Osmo and Landau, 2001) and more recently to human rights and decision making in child protection (Duffy et al, 2006). Toulmin’s model takes the practitioner through a series of stages where any argument or proposed recommendation (claim) is subjected to intense critical analysis involving exposition of its strengths and weaknesses. The author therefore proposes that explicit argumentation (Osmo and Landau, 2001) may help supervisors and practitioners towards safer and more confident decision making in child protection cases involving the interference of the human rights of children and parents. In addition to highlighting the broader context of human rights currently permeating child protection decision making, the paper will include case material to practically demonstrate the application of Toulmin’s model of argumentation to the supervision context. In this way the paper adopts a strong practice approach in helping to assist practitioners with the problems and dilemmas they may come up against in decision making in complex cases.