Initial Decision Research Articles

The influence of familial networks and stigma on prison-based medication initiation for individuals with opioid use disorder: Clinicians' perceptions

IntroductionIndividuals with criminal legal system (CLS) involvement experience opioid use disorder (OUD) at elevated rates when compared to their non-justice involved counterparts. Medications for opioid use disorder (MOUD) are efficacious but underutilized within this population. Interpersonal relationships and stigma play salient roles in the outcomes of OUD treatment. This study examines prison-based treatment staff perspectives on how familial networks and stigma interact to impact one's decision of whether to initiate MOUD while in prison in Kentucky. MethodsA coding team analyzed qualitative interviews with prison-based clinicians (n = 23) and administrators (n = 9) collected from the Geographic variation in Addiction Treatment Experiences (GATE) study using NVivo software. The study analyzed excerpts associated with the primary codes of “stigma” and “social networks” and the secondary code of “family” in order to assess the relationship between familial stigma and MOUD initiation from treatment staff viewpoints. ResultsArising themes suggest that clients' families' lack of MOUD knowledge plays a crucial role in perpetuating related stigma, that this stigma often materializes as a belief that MOUD is a continuation of illicit substance use and that stigma levels vary across MOUD forms (e.g., more stigma towards agonists than antagonists). ConclusionsThese findings carry implications for better understanding how intervention stigma within one's familial network impacts prison-based medication initiation decisions. Resulting themes suggest support for continued expansion of efforts by Kentucky Department of Corrections to involve participant families in education and treatment initiatives to reduce intervention stigma and increase treatment utilization.

Factors Influencing Parental Willingness to Consent to a Survey Study for Patients in the Pediatric Emergency Department.

To identify factors that impact parental willingness to consent to research studies conducted for their children during visits to pediatric emergency departments (EDs). Parents and guardians of children receiving care in our pediatric ED were approached and asked if they would be willing to let their child participate in a research study requiring the child to complete an electronic questionnaire. No such questionnaire existed, however, because the primary purpose was to ascertain the parent's willingness to let their child participate. All parents were debriefed and informed of the true purpose of the study and asked to complete a survey themselves to help understand factors that influenced their initial decision of whether to consent. Bivariate tests and logistic regression were used to evaluate unadjusted and adjusted associations between parent and patient characteristics and parental consent decision. We approached 431 eligible parents about the hypothetical research study involving their children, and 386 (89.6%) consented for their children to participate. After the debriefing, 392 (91.0%) parents consented to complete the parental survey. We observed statistically significant associations between shorter length of ED stay to approach for consent for the study ( P = 0.048) as well as longer travel time ( P = 0.03) and willingness to consent in bivariate analysis, though this did not hold in regression analysis. Regression analysis revealed parents of children who have previously participated in research had 79 times lower odds of consenting to participate in our study adjusted for parent race, ethnicity, actual and perceived length of stay, travel time to the ED, and altruism. A high proportion of parents consented to their child participating in research in our ED with previous child participation in research being associated with lower odds of parental consent even when adjusted for other factors. Our findings may inform future research practices and studies investigating parental perceptions and motivations surrounding research studies.

Why cannot reasons change your moral decisions? Because they are not persuasive enough: A comment on Stanley et al. (2018)

AbstractStanley et al. (2018) found that the consideration of reasons rarely induced people to change their moral decisions. We challenged this article by assuming what caused such a null or weak effect was that the persuasiveness of reasons provided to oppose the initial decisions was not strong enough. To verify our assumption, this study used Stanley et al.’s (2018) experimental paradigm and manipulated the levels of persuasiveness of reasons. The results revealed (1) that not only strong opposing reasons but also weak affirming reasons could induce changes in moral decision‐making and increase decision confidence after altering the decisions; (2) that people with a weak decision confidence tended to change their initial decisions after evaluation of reasons; and (3) that people who maintained their decisions after considering weak opposing reasons enhanced rather than reduced their decision confidence. Overall, these findings demonstrated that moral decision change was a composite outcome of the interaction among reason type, reason persuasiveness and initial decision confidence and that low‐quality argumentation had a boomerang effect on moral persuasion. This study re‐lifted the role of rational reasoning in moral decision‐making and revising, thus posing important amendments to Stanley et al.’s (2018) findings.

A two-level fusion model of vibro-acoustic signals for centrifugal fan blade crack detection

Blade crack detection is the key to ensuring the smooth and safe operation of centrifugal fans. However, a single vibration signal is difficult to fully reflect the health state of the blade and is susceptible to noise interference in the industrial field, which makes it difficult to detect blade cracks. Therefore, a two-level fusion model of vibro-acoustic signals is proposed for blade crack detection of centrifugal fans. Firstly, based on the designed correlated degree of cyclostationarity fusion rule, the data-level fusion of multi-source homogeneous vibro-acoustic signals is completed, and the fused signals with more obvious fault features are obtained. Then, a one-dimensional feature pyramid network is proposed to extract the vibro-acoustic features and generate initial decisions. Finally, a basic probability assignment acquisition method based on the precision of the initial classifiers and a weighted average method based on the Pignistic probability distance are proposed to minimize the conflict between multi-source evidence, and the Dempster-Shafer evidence theory method is used to obtain the blade crack detection results. The effectiveness of the proposed method is verified by the centrifugal fan blade crack detection experiments. Compared with other related methods, the proposed method has better detection performance and stronger robustness.

Associations between income and survival in cholangiocarcinoma: A comprehensive subtype-based analysis.

Socioeconomic determinants of health are incompletely characterized in cholangiocarcinoma (CCA). We assessed how socioeconomic status influences initial treatment decisions and survival outcomes in patients with CCA, additionally performing multiple sub-analyses based on anatomic location of the primary tumor. Observational study using the 2018 submission of the Surveillance, Epidemiology, and End Results (SEER)-18 Database. In total, 5,476 patients from 2004-2015 with a CCA were separated based on median household income (MHI) into low income (< 25th percentile of MHI) and high income (> 25th percentile of MHI) groups. Seventy-three percent of patients had complete follow up data, and were included in survival analyses. Survival and treatment outcomes were calculated using R-studio. When all cases of CCA were included, the high-income group was more likely than the low-income to receive surgery, chemotherapy, and local tumor destruction modalities. Initial treatment modality based on income differed significantly between tumor locations. Patients of lower income had higher overall and cancer-specific mortality at 2 and 5 years. Non-cancer mortality was similar between the groups. Survival differences identified in the overall cohort were maintained in the intrahepatic CCA subgroup. No differences between income groups were noted in cancer-specific or overall mortality for perihilar tumors, with variable differences in the distal cohort. Lower income was associated with higher rates of cancer-specific mortality and lower rates of surgical resection in CCA. There were significant differences in treatment selection and outcomes between intrahepatic, perihilar, and distal tumors. Population-based strategies aimed at identifying possible etiologies for these disparities are paramount to improving patient outcomes.

BIPOC students' paths to genetic counseling: Results from a longitudinal qualitative study.

Despite diversity initiatives, the genetic counseling profession continues to exhibit limited racial and ethnic diversity, with relatively stagnant representation of Black, Indigenous, and People of Color (BIPOC) individuals. Prior research has found that BIPOC high school and college students are less likely to be aware of genetic counseling and learn about it later than their white peers. Financial barriers and familial discouragement based on a preference for medical school may disproportionately impact BIPOC applicants. Here, we report the first set of results from a longitudinal constructivist grounded theory study exploring the training experiences of BIPOC genetic counseling students. Through reflexive thematic analysis of semi-structured interviews conducted with 26 first-year BIPOC genetic counseling students, we identified five themes pertaining to participants' paths to enrolling in a genetic counseling program: (1) Deciding to pursue genetic counseling, (2) Family's reaction to genetic counseling, (3) Deciding where to submit applications, (4) Barriers during admissions, and (5) Ranking programs. Participants discovered genetic counseling later in their academic journey, often necessitating gap years to complete admissions requirements. Limited guidance from advisors was commonly cited as a barrier by first-generation college students. Family support seems to be a key factor in participants' successful pursuit of genetic counseling, but participants described challenges explaining the career, particularly to parents who did not speak English. In addition, some participants encountered resistance about changing prior plans to go to medical school. Finally, while participants prioritized cost and location in their initial decision about where to submit applications, their ranking of programs was heavily influenced by experiences during interviews, where they favored conversational interviews and evaluated if they would "fit in" at the program. These findings underscore the need for proactive measures, such as early exposure initiatives, mentorship programs, and resources to facilitate family support, to promote diversity in genetic counseling.

Safety and clinical validity of tumor genomic testing for guiding active surveillance selection in men with NCCN intermediate-risk prostate cancer.

336 Background: Clinicopathologic features are considered the gold standard for predicting prostate cancer (PCa) disease severity and guiding decisions on the use of active surveillance (AS) or definitive treatment (DT). However, tumor genomic testing has been shown to provide valuable information as an addition to clinical risk stratification measures, allowing for more accurate identification of AS candidates. This study evaluated the safety of genomic testing for guiding AS selection in patients with National Comprehensive Cancer Network (NCCN) intermediate-risk PCa. Methods: In this retrospective observational cohort study, patients with NCCN intermediate-risk PCa underwent Prolaris testing at diagnosis from 9/2015–12/2018. The Prolaris test combines a molecular cell cycle progression score with clinicopathologic features (USCF Cancer of the Prostate Risk Assessment [CAPRA] score, inclusive of Gleason score), generating a Combined Clinical Risk (CCR) score to identify patients as candidates for AS or DT. Patients with a CCR-based 10-year disease-specific mortality (DSM) risk ≤3.2% were recommended to AS. Clinical follow up data, including initial treatment selection and time to metastasis, were retrospectively collected from the treating clinics. Kaplan-Meier estimates were used to evaluate the safety of AS in patients who initially selected AS. Cox proportional hazards models were used to evaluate CCR as a predictor of metastasis in all patients. Results: In total, 3204 patients were included in this analysis, with 1468 (46%) recommended to AS and 1736 (54%) recommended to DT. Among the 973 (30%) patients who initially selected AS, 613 (63%) were recommended to AS and 360 (37%) were recommended to DT. In patients who were recommended to AS and initially selected AS, the observed risk of metastasis within 5 years of diagnosis was 0.37% (95% confidence interval [CI], 0.09%–1.47%). Patients who were recommended to AS had a significantly lower rate of metastasis than patients who were recommended to DT after accounting for initial treatment decision (AS vs DT) and CAPRA score (hazard ratio 4.20 [95% CI, 1.41–18.04], P-value = 0.03). Conclusions: For patients with NCCN intermediate-risk PCa who were identified by genomic testing as candidates for AS, AS is safe based on the very low observed metastasis risk. The CCR score is a strong predictor of metastasis beyond clinicopathologic factors.

RT-PCR genotyping assays to identify SARS-CoV-2 variants in England in 2021: a design and retrospective evaluation study

Whole-genome sequencing (WGS) is the gold standard diagnostic tool to identify and genetically characterise emerging pathogen mutations (variants), but cost, capacity, and timeliness limit its use when large populations need rapidly assessing. We assessed the potential of genotyping assays to provide accurate and timely variant information at scale by retrospectively examining surveillance for SARS-CoV-2 variants in England between March and September, 2021, when genotyping assays were used widely for variant detection. We chose a panel of four RT-PCR genotyping assays to detect circulating variants of SARS-COV-2 in England and developed a decision algorithm to assign a probable SARS-CoV-2 variant to samples using the assay results. We extracted surveillance data from the UK Health Security Agency databases for 115 934 SARS-CoV-2-positive samples (March 1-Sept 6, 2021) when variant information was available from both genotyping and WGS. By comparing the genotyping and WGS variant result, we calculated accuracy metrics (ie, sensitivity, specificity, and positive predictive value [PPV]) and the time difference between the sample collection date and the availability of variant information. We assessed the number of samples with a variant assigned from genotyping or WGS, or both, over time. Genotyping and an initial decision algorithm (April 10-May 11, 2021 data) were accurate for key variant assignment: sensitivities and PPVs were 0·99 (95% CI 0·99-0·99) for the alpha, 1·00 (1·00-1·00) for the beta, and 0·91(0·80-1·00) for the gamma variants; specificities were 0·97 (0·96-0·98), 1·00 (1·00-1·00), and 1·00 (1·00-1·00), respectively. A subsequent decision algorithm over a longer time period (May 27-Sept 6, 2021 data) remained accurate for key variant assignment: sensitivities were 0·91 (95% CI 0·74-1·00) for the beta, 0·98 (0·98-0·99) for the delta, and 0·93(0·81-1·00) for the gammavariants; specificities were 1·00 (1·00-1·00), 0·96 (0·96-0·97), and 1·00 (1·00-1·00), respectively; and PPVs were 0·83 (0·62-1·00), 1·00 (1·00-1·00), and 0·78 (0·59-0·97), respectively. Genotyping produced variant information a medianof 3days (IQR 2-4) after the sample collection date, which was faster than with WGS (9days [8-11]). The flexibility ofgenotyping enabled a nine-times increase in the quantity of samples tested for variants by this method (from5000 to45 000). RT-PCR genotyping assays are suitable for high-throughput variant surveillance and could complement WGS, enabling larger scale testing for known variants and timelier results, with important implications for effective public health responses and disease control globally, especially in settings with low WGS capacity. However, the choice of panels of RT-PCR assays is highly dependent on database information on circulating variants generated by WGS, which could limit the use of genotyping assays when new variants are emerging and spreading rapidly. UK Health Security Agency and National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response.

The Influence of Entrepreneurship Education and Entrepreneurial Environment on Entrepreneurial Intentions Through Entrepreneurial Motivation in Private Vocational School Students in Mojokerto Regency

Measuring intentions or intentions in establishing a new business (new venture creation) needs to be done because in starting a business, various initial decisions are significantly related to forming business goals and strategies that can later determine the direction, sustainability, and growth of a business. The purpose of this study was to determine the influence of entrepreneurship education and entrepreneurial environment on entrepreneurial intentions through entrepreneurial motivation in private vocational school students in Mojokerto Regency. The population in this study was 233 students of Private Vocational School in Mojokerto Regency-Data collection using closed questionnaires. Data analysis techniques use descriptive statistics and Structural Equation Modelling Partial Least Squares (SEM-PLS). The results showed that 1. There is a direct influence of entrepreneurship education on entrepreneurial motivation; 2. There is an influence of the entrepreneurial environment on entrepreneurial motivation; 3. There is a direct influence of entrepreneurship education on entrepreneurial intentions; 4. There is a direct influence of the entrepreneurial environment on entrepreneurial intentions; 5. There is a direct influence of entrepreneurial motivation on entrepreneurial intentions; 6. There is an indirect influence of entrepreneurship education on entrepreneurial intentions through entrepreneurial motivation; 7. There is an indirect influence of the entrepreneurial environment on entrepreneurial intentions and entrepreneurial motivation

Endogenous Fungal Endophthalmitis: A Single-Center Retrospective Study and Review of the Literature

To evaluate factors that inform systemic antifungal choices in patients with endogenous fungal endophthalmitis (EFE). Single-institution retrospective case series. Charts of EFE patients from 2010 to 2023 were reviewed. Patients treated systemically for EFE with a minimum of 14 days of follow-up were included. Outcome measures included time to improvement in vitritis or chorioretinitis, systemic therapy modification, and need for surgical intervention. A total of 20 eyes of 16 patients were included. Candida species were most common (43.8%), followed by culture-negative EFE (37.5%) and Aspergillus species (18.8%). In all, 90% of eyes had vitritis and/or macula-involving chorioretinitis. The majority of Candida infections (60%) or culture-negative EFE (75%) were treated initially with oral antifungals. Patients with a history of immune compromise, positive fungal culture, or positive Fungitell assay were more likely to be treated with early intravenous (IV) antifungal therapy. Two patients required systemic antifungal therapy modification because of worsening chorioretinitis, in 1 case due to voriconazole-resistant Aspergillosis that demonstrated chorioretinal lesion growth despite intravitreal amphotericin B injections and systemic voriconazole, and in the second case due to worsening chorioretinitis from Candida dubliniensis infection that regressed upon switch from oral to IV fluconazole. Initial systemic treatment decisions in patients with EFE were driven by systemic culture positivity, systemic symptoms, or comorbidities. Intravitreal antifungal therapy may be insufficient to arrest progression of chorioretinal lesions in some cases. Larger studies are needed to determine whether visible end-organ damage in the form of chorioretinitis may be useful for guiding systemic therapy changes.

False memory-guided eye movements: insights from a DRM-Saccade paradigm

ABSTRACT The Deese-Roediger and McDermott (DRM) paradigm and visually guided saccade tasks are both prominent research tools in their own right. This study introduces a novel DRM-Saccade paradigm, merging both methodologies. We used rule-based saccadic eye movements whereby participants were presented with items at test and were asked to make a saccade to the left or right of the item to denote a recognition or non-recognition decision. We measured old/new recognition decisions and saccadic latencies. Experiment 1 used a pro/anti saccade task to a single target. We found slower saccadic latencies for correct rejection of critical lures, but no latency difference between correct recognition of studied items and false recognition of critical lures. Experiment 2 used a two-target saccade task and also measured corrective saccades. Findings corroborated those from Experiment 1. Participants adjusted their initial decisions to increase accurate recognition of studied items and rejection of unrelated lures but there were no such corrections for critical lures. We argue that rapid saccades indicate cognitive processing driven by familiarity thresholds. These occur before slower source-monitoring is able to process any conflict. The DRM-Saccade task could effectively track real-time cognitive resource use during recognition decisions.

Predicting advance rate and cutter life in TBM tunnelling using evolutionary algorithm

ABSTRACT Tunnelling with a Tunnel Boring Machine (TBM) offers several advantages over conventional tunnelling methods when covering long distances, particularly regarding time, safety, and environmental impact. Prior to starting a TBM project, performance analysis is a crucial stage necessary to inform the initial investment decision and project cost estimation. However, this analysis requires extensive fieldwork and laboratory studies. The Advance Rate (AR), calculated from the Utilization Factor (U) – the ratio of excavation time to total project time – is a widely accepted measure of TBM performance. Total project time encompasses various parameters, including boring time, cutter inspection and replacement times, and constant factors like re-gripping, service, and maintenance times. In this study, we employed analytical methods, statistical analysis, and genetic programming approaches to evaluate the AR and thus enhance TBM performance analysis. Gamma tests were conducted to identify interrelated parameters in TBM operations. The results from these tests showed that the Applied Force per Cutter (FN) and penetration values (together forming the Field Penetration Index or FPI) are useful in estimating cutter consumption. While FN can be determined through laboratory tests, its field determination is challenging. We have developed several charts and a function derived from genetic programming to estimate the AR of a TBM. The study demonstrated that this function, formulated using genetic programming, possesses strong predictive capability and can significantly improve TBM performance analysis.

Organ-preservation in rectal cancer: What is at risk when offering watch and wait for a clinical complete response? Data from 2 international registries in rectal cancer.

7 Background: Organ-preservation has become an attractive alternative to total mesorectal excision (TME) among patients with rectal cancer following neoadjuvant therapy. Patients who achieve a clinical complete response (cCR) are currently offered watch-and-wait (WW) without immediate resection. Nearly 30% of these patients will develop local regrowth usually within 3 years from initial decision to WW. While salvage resection is frequently feasible, keeping the primary tumor in situ (despite clinically undetectable) may contribute to the risk for development of subsequent distant metastases (DM). The aim of the present study is to compare the risk of DM between patients with local regrowth (LR) after WW (undetectable residual disease) and patients with near-complete pathological response managed by TME at time of reassessment of response. Methods: Data from patients with rectal cancer following neoadjuvant therapy entered a prospective international database (IWWD) with cCR managed by WW and subsequent LR were compared to patients managed by TME from a prospectively maintained national registry (VIKINGO project). Near-complete response was defined at the presence of ≤10% residual cancer cells in the resected specimen. Primary endpoint was DM-free survival at 3 years from decision to WW or TME. Cox-logistic regression was performed to search for predictors of DM development. Kaplan-Meier curves were used to compare DM-free survival between groups based on statistically significant features found at multivariate analysis (p≤0.05) using log-rank test. Results: 508 patients with LR were compared to 893 patients with near-complete response after TME. Overall, DM rate was significantly higher among local regrowths (22.8% vs. 10.2%,; p≤0.001). Independent risk factors for DM included LR (versus TME at reassessment; p=0.001), ypT3-4 status (p=0.016) and ypN+ status (p=0.001) at the time of surgery. 3yr-DM-free survival was significantly worse for patients with local regrowth (75% vs. 87%; p=0.001). When stratified for pathological stage, patients with local regrowth did significantly worse through all stages ypT1-2N0 (p&lt;0.001); ypT3-4N0 (p=0.009) and ypTanyN+ (p&lt;0.001). Conclusions: Development of LR following WW is a significant and independent risk factor for subsequent DM. Final pathological stage is also a risk factor for subsequent DM. Patients with local regrowth have a higher risk for subsequent DM development than patients managed by TME at restaging irrespective of final ypT and ypN status. Leaving the primary undetectable tumor in situ until development of local regrowth may result in worse oncological outcomes. Future studies incorporating organ-preservation strategies should focus on the subsequent risk of DM among patients who eventually develop local regrowth as one of clinically relevant primary endpoints.

How do low-education immigrants adjust to Chinese import shocks? Evidence using English language proficiency

This paper examines the link between trade-induced changes in local labor market opportunities and English language fluency rates among low-education immigrants in the United States. The production-based manufacturing jobs lost due to Chinese import competition around the turn of the century did not require strong English-speaking skills while many of the jobs in expanding industries, mostly in the service sector, did. Consistent with responses to these changing labor market opportunities, we find that a $1,000 increase in import exposure per worker in a local area led to an increase in the share of low-education immigrants speaking English very well in that area by about half a percentage point. As evidence that at least part of this is a result of actual improvements in English language speaking abilities, we show that low-education immigrants in trade-impacted areas became especially likely to be enrolled in school compared to similarly low-education natives. While we find some evidence for domestic migration in response to trade shocks, we also show that our results are not likely to be driven by language-selective internal migration or initial settlement decisions.

Complex Characteristics and Control of Output Game in Cross-Border Supply Chains: A Perspective of Inter-Chain Competition

In this paper, an output dynamic game model of intertwined supply chains operating in two different countries is established. The Nash equilibrium point of the model and its stable region are obtained using nonlinear dynamic principles. The complex properties of the system, such as stability, period-doubling bifurcations, and chaos, are investigated using numerical simulations. Our results suggest that the level of output and the system’s profits undergo bifurcation and chaos with an increase in the output adjustment speed. An interesting phenomenon occurs in that higher tariffs lead to the expansion of the stable range of the supply chain in the product-exporting country. The chaotic behavior of the system is sensitive to the value of the initial level of output. In supply chain competition, each supply chain firm should make suitable adjustments to the speed of output. To maintain the stability of domestic markets, excessive tariffs should be avoided. It is essential that each supply chain firm evaluates the potential impacts of different initial output values when making initial decisions. Using the method of delayed feedback control, the chaotic behavior of the system can effectively be controlled. These findings offer valuable and novel insight into inter-chain competition in supply chain networks.

Automated Paper Screening for Clinical Reviews Using Large Language Models: Data Analysis Study.

The systematic review of clinical research papers is a labor-intensive and time-consuming process that often involves the screening of thousands of titles and abstracts. The accuracy and efficiency of this process are critical for the quality of the review and subsequent health care decisions. Traditional methods rely heavily on human reviewers, often requiring a significant investment of time and resources. This study aims to assess the performance of the OpenAI generative pretrained transformer (GPT) and GPT-4 application programming interfaces (APIs) in accurately and efficiently identifying relevant titles and abstracts from real-world clinical review data sets and comparing their performance against ground truth labeling by 2 independent human reviewers. We introduce a novel workflow using the Chat GPT and GPT-4 APIs for screening titles and abstracts in clinical reviews. A Python script was created to make calls to the API with the screening criteria in natural language and a corpus of title and abstract data sets filtered by a minimum of 2 human reviewers. We compared the performance of our model against human-reviewed papers across 6 review papers, screening over 24,000 titles and abstracts. Our results show an accuracy of 0.91, a macro F1-score of 0.60, a sensitivity of excluded papers of 0.91, and a sensitivity of included papers of 0.76. The interrater variability between 2 independent human screeners was κ=0.46, and the prevalence and bias-adjusted κ between our proposed methods and the consensus-based human decisions was κ=0.96. On a randomly selected subset of papers, the GPT models demonstrated the ability to provide reasoning for their decisions and corrected their initial decisions upon being asked to explain their reasoning for incorrect classifications. Large language models have the potential to streamline the clinical review process, save valuable time and effort for researchers, and contribute to the overall quality of clinical reviews. By prioritizing the workflow and acting as an aid rather than a replacement for researchers and reviewers, models such as GPT-4 can enhance efficiency and lead to more accurate and reliable conclusions in medical research.

Concussion-Related Decision-Making by Certified Athletic Trainers: Implications for Concussion Prevention and Care.

Concussions are a common sport-related injury that require appropriate initial care. Athletic trainers, often a primary source of healthcare for student-athletes, are key individuals involved in initial concussion diagnostic and management decisions. Challenges exist within the athletic environment that may hinder the consistency, efficacy, and/or effectiveness of concussion-related decision-making by athletic trainers, thereby impacting secondary concussion prevention and patient health. The purpose of this study was to identify factors that impact the intentions of athletic trainers to make appropriate concussion-related decisions under various circumstances. Overall, 1029 participants completed a survey examining educational precursors (quantity and quality of healthcare communication educational focus), demographic precursors (age, gender, educational degree, and employment setting), theory-based mediators (attitudes, perceived norms, and personal agency), and external mediators (knowledge, salience, and communication/collaboration practices) on appropriate concussion-related decision-making intentions. Data were analyzed using a two-step structural equation modeling approach. Quality of healthcare communication educational focus indirectly impacted appropriate concussion-related decision-making intentions via perceived behavioral control and communication/collaboration practices. Additionally, several factors impacted intentions to make appropriate concussion-related decisions directly including employment setting, self-efficacy, and general attitudes towards decision-making and concussions. Concussion prevention is aided by the initial and appropriate action taken by a healthcare professional to reduce immediate consequences; however, this action may be influenced by stakeholder relationships. These influential factors of decision-making may place athletes at further injury risk and negatively impact overall athlete health. As such, a sound theoretical framework incorporating the complexity of factors that may influence decision-making is needed.

Project management approaches and their selection in the digital age: Overview, challenges and decision models

Digital transformation is a challenge that also impacts the selection of tools for implementing projects. Which tools are suitable for handling complex digital twins? Project management must respond to this with suitable approaches. The challenge for decision-makers is to choose the right one. Based on literature research and a case study, influencing factors are derived and practice-relevant project management approaches are collected. Furthermore, a decision model is developed that, on the one hand, supports the decision-maker in selecting tools before and during the project, and on the other hand makes empirical values from past projects usable for future decisions. The results show that the number of influencing factors is large, and the approaches are di-verse. In complex projects, this can lead to complex decision-making situations that require appropriate decision models. The developed “Supervised Decision Model – L5” is based on five levels (L): (L1) Building a database; (L2) Derivation of algorithms; (L3) Initial approach selection; (L4) Review of the initial selection; (L5) Using experiences for future decisions. In practice it turns out that complex projects – like Digital Twins - often fail. Modified decision models for selecting suitable approaches should therefore take the following as-pects into account: (a) decision-makers are actively supported in the initial decision phase; (b) initial decisions once made are checked in the early phase of the project and corrected if necessary; (c) the lessons learned are recorded in the database as empirical value and used for future decisions.

The Impact of Insurance Restrictions in Newly Diagnosed Individuals With Multiple Sclerosis.

The medical system in the United States has been riddled with insurance restrictions used by insurance companies to limit health care costs. The effects of insurance restrictions on patients receiving disease-modifying therapies for multiple sclerosis (MS) have not been specifically studied. A retrospective cross-sectional study of 52 individuals recently diagnosed with MS at a tertiary neurology clinic was conducted to measure the association between prior authorization (PA) duration and other variables of interest. The Cox proportional hazards model was used to determine likelihood of approval. Further analysis included multivariable logistic regression to assess the influence of variables of interest on the initial decision from the insurance company and the effect of the PA on disease activity. Of 52 PAs, 50% were initially denied. An initial denial decreased the likelihood of approval by 98% (HR, 0.02; 95% CI, <0.01-0.09; P < .001). The odds of denial for oral medications (odds ratio [OR], 4.91; 95% CI, 1.33-21.52; P = .02) and infusions (OR, 8.35; 95% CI, 1.10-88.77; P = .05) were significantly higher than for injections. Medicaid had higher odds of denial compared with commercial insurance (OR, 4.51; 95% CI, 1.13-22.01; P = .04). An initial denial by insurance significantly increased the likelihood of disease activity (OR, 6.18; 95% CI, 1.33-44.86; P = .03). Insurance restrictions delay necessary treatments, increase the likelihood of disease activity, and rarely change the approved disease-modifying therapy. Reducing PAs may lead to improved outcomes for patients with MS.

Management patterns of multiple magnet ingestion reported to New Jersey Poison Information and Education System.

Ingestion of multiple high-powered neodymium rare-earth magnets poses a significant risk for gastrointestinal (GI) injury such as bowel perforation or ischemia. Given the rising incidence of rare earth magnetic ingestions and the corresponding increase in serious injuries in children, published guidelines recommend urgent endoscopic removal of all magnets within endoscopic reach in cases involving ingestions of two or more magnets. Do management patterns for multiple magnet ingestion align with current practice guidelines, and does hospital length of stay (LOS) differ based on the initial emergency department (ED) approach? This is a retrospective chart review of consecutive patient encounters reported to the New Jersey Poison Information and Education System (NJPIES) between January 2021 and April 2022 involving multiple magnet ingestion. Potential cases were retrieved from the NJPIES TOXICALL® database, using substance codes relating to magnet or foreign body ingestion. Two-sample T tests were used to determine the statistical difference in the hospital LOS between the group of patients receiving early emergent esophagogastroduodenoscopy (EGD) versus those receiving expectant management on initial presentation. There was a difference in the average LOS of 2.7 days (p = 0.023)longer in the expectant management group with no medical complications in either group. Twenty-five percent or 2 out of 8 cases deviated from guidelines. The initial ED decision to pursue expectant management instead of attempting emergent EGD removal of magnets may result in prolonged hospitalization, increased risk for readmission, and delayed definitive removal of magnets due to nonprogression along the GI tract.