Risk-benefit Calculus Research Articles

Examining the link between distressing life events, social media distress disclosure, and perceived stress: A moderated mediation model

People share not only positive but also distressing personal information on social media. Although much work has been done to understand distress disclosure practices on social media, little is known about the association between social media distress disclosure and different components of disclosure risk, as well as the link between distressing life events, social media distress disclosure, and psychological well-being. This study examines the theoretical antecedents (i.e., situational and non-situational factors) of social media distress disclosure and tests a moderated mediation model that assesses the mediator role of social media distress disclosure on the relationship between distressors (i.e., frequency and intensity of distressing life events) and perceived stress. Results from an online survey (n = 967) revealed that social media users’ distress disclosure frequency is associated with both situational (i.e., distressing life events and exposure to others’ distress disclosure) and non-situational (i.e., perceived risks and benefits of distress disclosure) factors. Specifically, the findings indicated that social media users’ distress disclosure frequency was not only affected by self-oriented risk but also other-oriented risk—imposition risk. Furthermore, the moderated mediation model revealed that the association between distressors and perceived stress was mediated by social media distress disclosure frequency, and this mediated relationship was moderated by risk-benefit calculus and satisfaction with social media distress disclosure. Overall, this study advances our understanding of social media distress disclosure and extends existing self-disclosure theories by specifying the conditions by which individuals can expect an improvement in psychological well-being following disclosure of distressing information on social media.

Severity of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Pregnancy in Ontario: A Matched Cohort Analysis.

Pregnancy represents a physiological state associated with increased vulnerability to severe outcomes from infectious diseases, both for the pregnant person and developing infant. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic may have important health consequences for pregnant individuals, who may also be more reluctant than nonpregnant people to accept vaccination. We sought to estimate the degree to which increased severity of SARS-CoV-2 outcomes can be attributed to pregnancy using a population-based SARS-CoV-2 case file from Ontario, Canada. Because of varying propensity to receive vaccination, and changes in dominant circulating viral strains over time, a time-matched cohort study was performed to evaluate the relative risk of severe illness in pregnant women with SARS-CoV-2 compared to other SARS-CoV-2 infected women of childbearing age (10-49 years old). Risk of severe SARS-CoV-2 outcomes was evaluated in pregnant women and time-matched nonpregnant controls using multivariable conditional logistic regression. Compared with the rest of the population, nonpregnant women of childbearing age had an elevated risk of infection (standardized morbidity ratio, 1.28), whereas risk of infection was reduced among pregnant women (standardized morbidity ratio, 0.43). After adjustment for confounding, pregnant women had a markedly elevated risk of hospitalization (adjusted odds ratio, 4.96; 95% confidence interval, 3.86-6.37) and intensive care unit admission (adjusted odds ratio, 6.58; 95% confidence interval, 3.29-13.18). The relative increase in hospitalization risk associated with pregnancy was greater in women without comorbidities than in those with comorbidities (P for heterogeneity, .004). Given the safety of SARS-CoV-2 vaccines in pregnancy, risk-benefit calculus strongly favors SARS-CoV-2 vaccination in pregnant women.

Attitudes Toward Payment for Research Participation: Results from a U.S. Survey of People Living with HIV

Little is known about how payment affects individuals' decisions to participate in HIV research. Using data from a U.S. survey of people living with HIV (N = 292), we examined potential research participants’ attitudes toward payment, perceived study risk based on payment amount, and preferred payment forms, and how these factors vary by sociodemographic characteristics. Most respondents agreed people should be paid for HIV research participation (96%) and said payment would shape their research participation decisions (80%). Men, less formally educated individuals, and members of some minoritized racial-ethnic groups were less likely to be willing to participate in research without payment. Higher payment was associated with higher perceived study risks, while preferences for form of payment varied by age, gender, education, race-ethnicity, and census region of residence. Findings suggest payment may influence prospective research participants’ risk–benefit calculus and participation, and that a one-size-fits-all approach to payment could differentially influence participation among distinct sociodemographic groups.

Association of Bleeding Severity With Mortality in Extended Thromboprophylaxis of Medically Ill Patients in the MAGELLAN and MARINER Trials.

Extended thromboprophylaxis has not been widely implemented in acutely ill medical patients because of bleeding concerns. The MAGELLAN (Multicenter, Randomized, Parallel Group Efficacy and Safety Study for the Prevention of Venous Thromboembolism in Hospitalized Medically Ill Patients Comparing Rivaroxaban With Enoxaparin) and MARINER (Medically Ill Patient Assessment of Rivaroxaban Versus Placebo in Reducing Post-Discharge Venous Thrombo-Embolism Risk) trials evaluated whether rivaroxaban compared with enoxaparin or placebo could prevent venous thromboembolism without increased bleeding. We hypothesized that patients with major bleeding but not those with nonmajor clinically relevant bleeding would be at an increased risk of all-cause mortality (ACM). We evaluated all bleeding events in patients taking at least 1 dose of study drug and their association with ACM in 4 mutually exclusive groups: (1) no bleeding, or first event was (2) nonmajor clinically relevant bleeding, (3) major bleeding, or (4) trivial bleeding. Using a Cox proportional hazards model adjusted for differences in baseline characteristics associated with ACM, we assessed the risk of ACM after such events. Compared with patients with no bleeding, the risk of ACM for patients with nonmajor clinically relevant bleeding was not increased in MARINER (hazard ratio, 0.43; P=0.235) but was increased in MAGELLAN (hazard ratio, 1.74; P=0.021). Major bleeding was associated with a higher incidence of ACM in both studies, whereas trivial bleeding was not associated with ACM in either study. Patients with major bleeding had an increased risk of ACM, whereas nonmajor clinically relevant bleeding was not consistently associated with an increased risk of death. These results inform the risk-benefit calculus of extended thromboprophylaxis in medically ill patients. URL: https://www. gov; Unique identifier: MAGELLAN, NCT00571649. URL: https://www. gov; Unique identifier: MARINER, NCT02111564.

Society for Maternal-Fetal Medicine Consult Series #59: The use of analgesia and anesthesia for maternal-fetal procedures

Pain is a complex phenomenon that involves more than a simple physical response to external stimuli. In maternal-fetal surgical procedures, fetal analgesia is used primarily to blunt fetal autonomic responses and minimize fetal movement. The purpose of this Consult is to review the literature on what is known about the potential for fetal awareness of pain and to discuss the indications for and the risk-benefit calculus involved in the use of fetal anesthesia and analgesia. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that fetal paralytic agents be considered in the setting of intrauterine transfusion, if needed, for the purpose of decreasing fetal movement (GRADE 2C); (2) although the fetus is unable to experience pain at the gestational age when procedures are typically performed, we suggest that opioid analgesia should be administered to the fetus during invasive fetal surgical procedures to attenuate acute autonomic responses that may be deleterious, avoid long-term consequences of nociception and physiological stress on the fetus, and decrease fetal movement to enable the safe execution of procedures (GRADE 2C); and (3) due to maternal risk and a lack of evidence supporting benefit to the fetus, we recommend against the administration of fetal analgesia at the time of pregnancy termination (GRADE 1C).

Society for Maternal-Fetal Medicine Consult Series #59: The use of analgesia and anesthesia for maternal-fetal procedures

Pain is a complex phenomenon that involves more than a simple physical response to external stimuli. In maternal-fetal surgical procedures, fetal analgesia is used primarily to blunt fetal autonomic responses and minimize fetal movement. The purpose of this Consult is to review the literature on what is known about the potential for fetal awareness of pain and to discuss the indications for and the risk-benefit calculus involved in the use of fetal anesthesia and analgesia. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that fetal paralytic agents be considered in the setting of intrauterine transfusion, if needed, for the purpose of decreasing fetal movement (GRADE 2C); (2) although the fetus is unable to experience pain at the gestational age when procedures are typically performed, we suggest that opioid analgesia should be administered to the fetus during invasive fetal surgical procedures to attenuate acute autonomic responses that may be deleterious, avoid long-term consequences of nociception and physiological stress on the fetus, and decrease fetal movement to enable the safe execution of procedures (GRADE 2C); and (3) due to maternal risk and a lack of evidence supporting benefit to the fetus, we recommend against the administration of fetal analgesia at the time of pregnancy termination (GRADE 1C).

PL6. Treatment continuum of nonconvulsive status epilepticus

Acute seizures and status epilepticus (SE) are commonly encountered in critically ill patients. With continuous EEG (cEEG) monitoring it is possible to differentiate whether patients are in on-going, continuous SE or having intermittent electrographic seizures. This data should be used to determine the urgency and aggressiveness of treatment for each patient. In this presentation the rationale for “appropriately aggressive” treatment will be discussed in the context of the risk-benefit calculus. Initially the evolving definition of SE will be discussed. This will be followed by a discussion about measuring the severity of electrographic SE, and how this is valuable in determining appropriate therapeutic targets. Finally, the concept of “appropriately aggressive” therapy for SE will be discussed.

Controversies and Advances in Adult Intracranial Bypass Surgery in 2020

Cerebral revascularization utilizing a variety of bypass techniques can provide either flow augmentation or flow replacement in the treatment of a range of intracranial pathologies, including moyamoya disease, intracranial atherosclerotic disease, and complex aneurysms that are not amenable to endovascular or simple surgical techniques. Though once routine, the publication of high-quality prospective evidence, along with the development of flow-diverting stents, has limited the indications for extracranial-to-intracranial (EC-IC) bypass. Nevertheless, advances in imaging, assessment of cerebral hemodynamics, and surgical technique have changed the risk-benefit calculus for EC-IC bypass. New variations of revascularization surgery involving multiple anastomoses, flow preserving solutions, IC-IC constructs, and posterior circulation bypasses have been pioneered for otherwise difficult to treat pathology including giant aneurysms, dolichoectasia, and medically refractory intracranial atherosclerosis. This review provides a practical update on recent advances in adult intracranial bypass surgery.

Patient Counseling in Plastic Surgery during Coronavirus Disease 2019.

Sir, Coronavirus disease 2019 (COVID-19) remains an ongoing public health crisis. As of April 19, 749,666 cases and 35,012 deaths have been confirmed in the United States.1 In response, hospitals have implemented significant changes to normal operating procedures to address anticipated needs of infected patients. One key example is cancellation of non–time-sensitive elective surgery. Because the majority of plastic surgical procedures fall under this classification, the current pandemic has profound effects on plastic surgery. Due to effective social distancing, recent models report reduced COVID-19–related death estimates and flattening of the curve.2 In response, hospitals have started preparing for a return to normal operations. Several institutions, including ours, recently relaxed restrictions on surgery, permitting some elective procedures to proceed. It is, therefore, critical that both surgeons and patients understand additional risks present in the setting of the COVID-19 pandemic. A recent report by Bryan et al3 highlighted several considerations for surgical patients during the pandemic (Table 1). First, there is a lack of evidence demonstrating how infected patients tolerate routine procedures, including physiologic response to surgery and anesthesia. Second, patients have an unknown but presumably heightened risk of nosocomial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Third, changes in normal perioperative procedures, such as visitor restrictions or limited nursing staff, may impact care. Finally, resource shortages may alter postoperative care, both in cases of successful surgery and when complications arise.3 We agree on the importance of informing patients of these issues. However, there are risks specific to plastic surgery that must also be addressed (Table 1). First, there appears to be an increased risk of thromboembolic complications in COVID-19–positive patients.4 Whether this translates to an increased risk of thrombosis in microvascular surgery or for procedures with a high relative risk of thromboembolism (eg, abdominoplasty) remains uncertain. Second, many procedures are staged, such as prosthetic breast reconstruction and forehead flaps. Due to unforeseen issues related to the pandemic, patients may experience atypically long delays to the second procedure. Similarly, revision surgery may be delayed indefinitely if hospital resources become limited. Third, although changes to the risk–benefit calculus for common procedures are expected, the degree of change remains unknown. For example, evidence regarding the safety of delaying versus performing nonelective, nonemergent surgery (eg, skin cancer resection) in patients at risk for severe COVID-19 infection (eg, elderly and/or comorbidities) is limited. Additional risks will certainly arise in specific cases and must be addressed accordingly. Table 1. - Considerations for Patients Undergoing Surgery during the COVID-19 Pandemic Surgical considerations3 • Uncertainty regarding physiologic response of COVID-19–positive patients to surgery and anesthesia• Theoretical risk of nosocomial SARS-CoV-2 infection• Unforeseen changes to normal perioperative care and experience• Unforeseen changes to routine postoperative care Plastic surgical considerations • Potential for thrombotic complications in microvascular procedures and procedures with an increased relative risk of thrombosis• Possible indefinite delays in staged procedures and common revision procedures• Unknown changes to risk–benefit calculus of nonelective, nonemergent procedures (eg, skin cancer excision) Moving forward, we offer recommendations to facilitate appropriate care during the pandemic (Table 2). First, during the informed consent process, in addition to case-specific risks, benefits, and alternatives, implications of surgery during the pandemic must be discussed and documented accordingly. Next, whenever possible, patients should undergo preoperative COVID-19 testing. This has the added benefit of protecting healthcare personnel who come into contact with the patient. Additionally, as noted by Bryan et al,3 the use of advanced directives and living wills is encouraged, given the high degree of uncertainty surrounding surgery and COVID-19.3 Finally, application of sound clinical judgment, shared decision-making, and a patient-centered approach will facilitate improved care, particularly where clinical evidence is lacking.5 Table 2. - Recommendations of Counseling Strategies during the COVID-19 Pandemic • During informed consent process, include discussion of additional risks and uncertainties to surgical patients• Document informed consent discussion, including additional COVID-19–specific risks discussed• When possible, order preoperative COVID-19 testing• Encouragement of using advanced directives and/or living wills• Employment of a shared decision-making model and patient-centered approach• Employment of sound clinical judgment Disclosure The authors have no financial interest to declare in relation to the content of this article.

Paediatric deep brain stimulation: ethical considerations in malignant Tourette syndrome

Gilles de la Tourette syndrome (TS) is a childhood neuropsychiatric disorder characterised by the presence of motor and vocal tics. Patients with malignant TS experience severe disease sequelae; risking morbidity...

Consumer acceptance of personalised nutrition: The role of ambivalent feelings and eating context.

Providing dietary suggestions based on an individual's nutritional needs may contribute to the prevention of non-communicable dietary related diseases. Consumer acceptance is crucial for the success of these personalised nutrition services. The current study aims to build on previous studies by exploring whether ambivalent feelings and contextual factors could help to further explain consumers' usage intentions regarding personalised nutrition services. An online administered survey was conducted in December 2016 with a final sample of 797 participants in the Netherlands. Different models were tested and compared by means of structural equation modelling. The final model indicated that the result of weighing personalisation benefits and privacy risks (called the risk-benefit calculus) is positively related to the intention to use personalised nutrition advice, suggesting a more positive intention when more benefits than risks are perceived. Additionally, the model suggests that more ambivalent feelings are related to a lower intention to use personalised nutrition advice. Finally, we found that the more the eating context is perceived as a barrier to use personalised nutrition advice, the more ambivalent feelings are perceived. In conclusion, the current study suggests the additional value of ambivalent feelings as an affective construct, and eating context as a possible barrier in predicting consumers' intention to use personalised nutrition advice. This implies that personalised nutrition services may need to address affective concerns and consider an individual's eating context.

Diagnostic Evaluation of Pulmonary Embolism During the COVID-19 Pandemic

The rapid emergence of the COVID-19 pandemic has altered the risk–benefit calculus of many activities, including the practice of medicine. COVID-19 is caused by a single-strand RNA virus, SARS-CoV-2, belonging to the Coronaviridae family. The virus is known to infect the upper respiratory tract

Abstract P2-16-29: De-escalating care using computational oncology

Abstract Introduction: When considering the use of NACT for breast cancer, healthcare providers and patients must weigh the risks associated with different potential standard of care (SoC) treatment regimens against the likelihood of achieving a desired outcome. The decision of treatment option is currently made using standard NCCN guidelines matched with diagnostic data, population statistics derived from clinical trials of the regimens and a clinician’s expert judgement. Given the potential variability in decision making, there is a significant need to standardize how data is used in this process and the ability to systematically individualize the treatment decision for a patient. This individualization presents the opportunity to lower toxicity and costs where the response would be identical. This was a major topic at the 2019 American Society of Clinical Oncology (ASCO) Annual meeting with multiple oncologists and researchers seeking methods to deescalate care. Method: Among the most common choices, anthracycline-based regimens are associated with only marginally better clinical outcomes than comparable taxane-based regimens (2.5% difference in 4-year disease free survival [Blum et al. 2017]), but they carry greater risks of cardiotoxicity and secondary leukemia. They are both preferred regimens per NCCN guidelines in HER2-negative breast cancer, which leaves the decision of when to use which regimen largely up the healthcare provider. With the rise of targeted but expensive therapies like trastuzumab and pertuzumab, and immunotherapies like pembrolizumab in clinical trials, the risk-benefit calculus is becoming even more complex. Moreover, the goals of NACT often vary from patient to patient. While complete pathological response is always the ideal, NACT is routinely used to downstage a tumor in order to enable breast conserving surgery or to simplify the tumor's resection. With the above in mind, we selected and reviewed tumor response of 50 randomly selected patients from the ISPY 1 dataset (measured via initial, inter-regimen and pre-surgery MRIs) and utilized the SimBioSys TumorScope in silico simulations to predict response to alternate therapies. Results: Using the base data set and tumor response resulting from the AC (anthracycline + cyclophosphamide) regimen compared to resulting response from the T (Paclitaxel) arm of the regimen. 22 out of the 50 patients were shown to have a superior response to the T. For this analysis, we ignored the synergistic effect of the use of AC prior to the T. Since both Docetaxel and Paclitaxel are taxanes, the analysis provided ideal candidates for the in-silico simulation of these patients using the TC regimen (known to be less toxic). The analysis showed a majority number of patients that had similar (~5% variation) responses to TC as they did with AC. This was clearly depicted by Study ID 1217 where both ACT and TC would lead to pCR. More promisingly, there was a subset of patients that would achieve pCR with the TC regimen vs the ACT such as Study ID 1127. Conclusion: While the results above are preliminary and will be further expanded via a future prospective study, there is clearly an opportunity for us to address the variation that exists in ACT vs TC selection. Whether it’s treatment in the East vs West Coast or a community vs an academic medical center, the variation in opinion is undeniable. There is a need to standardize yet individualize how this decision is made today - an in-silico determination might be solution. Citation Format: Tushar Pandey, Joseph Peterson, Eduardo Braun, John Cole. De-escalating care using computational oncology [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-16-29.

'I feel like a person has a right to use a product to protect themselves…': a qualitative study of the risk-benefit calculus on women's contraceptive use and choice.

Women used one or more contraceptive methods, each for 3-6 months. Qualitative data from individual in-depth interviews completed after each 3-month use period were analysed using a summary matrix framework. Data were extracted and summarised into themes. Each woman's experiences were compared among the methods she used; comparisons were also made across participants. The data consist of 33 90-120 min in-depth qualitative interviews from 16 women aged 20-34 years, in which they discussed various elements of their method use experience. One prominent theme was identified: the influence of attitudes and beliefs on the risk-benefit calculus. There were six key elements within the theme: pregnancy prevention; dosing and the potential for user error; side-effects; familiarity; disclosure; and sexual partnerships. Women weighed perceived risks and benefits in their decision-making and, ultimately, their contraception choices. Understanding women's beliefs and attitudes that contribute to a calculation of risk-benefit can inform the development of sexual and reproductive health products.

Thromboprophylactic Efficacy and Safety of Anticoagulants After Arthroscopic Knee Surgery: A Systematic Review and Meta-Analysis.

To examine the efficacy and safety of anticoagulants after knee arthroscopy (KA), PubMed, EMBASE, databases of Cochrane Central Register of Controlled Trials, and Chinese National Knowledge Infrastructure were searched up to August 2019 for randomized controlled trials (RCT). Seven RCTs including 4097 patients were demonstrated eligible according to the inclusion and exclusion criteria. The efficacy and safety of thromboprophylaxis were assessed and expressed using relative risk (RR) and 95% confidence intervals (95% CIs). The analysis of pooled data showed that anticoagulants group exhibited significant lower overall incidence of symptomatic and asymptomatic venous thromboembolism (VTE; RR = 0.35, 95% CIs: 0.22-0.55, P < .00001), significant higher incidence of all bleeding events (RR = 1.42, 95% CIs: 1.08-1.86, P = .01) compared to control group. However, no significant difference was found in terms of incidence of symptomatic VTE (RR = 0.43, 95% CIs: 0.15-1.21, P = .11) and incidence of major bleeding events (RR = 1.87, 95% CIs: 0.40-8.67, P = .42). The pooled number needed to treat to prevent one symptomatic or asymptomatic VTE was 26, while the pooled number needed to harm to cause one major bleeding event was 869. These results show that anticoagulants can effectively reduce the overall risk of VTE after KA; however, the increased risk of bleeding should be fully considered. Further studies are required to address the risk–benefit calculus and cost-effectiveness of anticoagulants after KA.

The Inappropriate Use of Risk-Benefit Analysis in the Risk Assessment of Experimental Trauma-Focused Research

ABSTRACTA large body of research has explored the impact of questioning participants about traumatic experiences. To determine the level of risk, these studies have relied, to various degrees, upon a risk-benefit calculus, whereby risks are weighed against the benefits that an individual can receive from participating. In the case of trauma-focused studies this approach is erroneous. The procedures involved in trauma-focused studies do not meet the criteria to be considered therapeutic, and the benefits associated with these procedures do not carry the moral weight to offset risk. Applying the risk-benefit calculus to non-therapeutic procedures inevitably leads to inaccurate risk assessments and ethically problematic claims, examples of which can be found throughout traumatic stress literature. This article outlines how the standard approach to risk assessment in trauma-focused studies is fallacious, and presents an established alternative model that researchers can use to accurately assess the risks of asking participants about their traumatic experiences.

Risks and benefits of trial participation: A qualitative study of participants' perspectives in Russia.

The Russian Federation is one of the emerging clinical trial regions where the numbers of international clinical trials have been significantly rising over the course of recent years. Our aims were to describe and explain risk-benefit calculus by clinical trial participants in Russia and to analyse the significance of the results for the ethical regulation of globalizing clinical trials. In-depth semi-structured interviews were conducted with 21 individuals participating in trials for cardiovascular disease. Analysis was based on the inductive constant comparative method. Interviewed participants perceived multiple benefits in trial enrolment including regular check-ups, provision and explanation of individual test results, the opportunity to ask investigators for advice and the provision of treatment recommendations for those with limited access to a physician outside of the trial. Participants tried to manage risks of trial enrolment by paying attention to how they felt and reporting changes to investigators. Regular monitoring, the opportunity to drop out of the trial and health insurance provision in case of adverse events were viewed as further minimizing individual risks. Importantly, interviewed trial participants did not assess the risks and benefits of a single trial independently of wider social situation or particularities of their own health condition. Value of trial enrolment benefits for participants was enhanced by the healthcare system that was viewed as being unresponsive to the needs of people with cardiovascular disease. Therefore, in their risk-benefit assessment, participants weighed enrolment risks against the risks of dealing with their fragile health without continuous contact with a medical professional. A relatively small number of interviews was conducted, only participants of cardiovascular disease trials were interviewed and the extent to which the described perspectives are generalizable is not established. The risk-benefit assessment as performed by most interviewed trial participants involved multiple components, including the ones unrelated to the trial itself, and was largely context-dependent. Perspectives of research participants can enrich frameworks for the evaluation of trial risks and benefits.

Pharmaceutical manufacturer liability for unreasonable marketing

The Supreme Court of Pennsylvania recently reversed dismissal of a lawsuit brought against a pharmaceutical manufacturer. That court accepted the argument that a manufacturer may be liable for marketing a drug that is unreasonably dangerous for any patient. This ruling has the potential to expand the liability of pharmaceutical manufacturers beyond the traditional lawsuits based on manufacturing defects and the failure to warn.

What's in a story? Lessons from patients who have suffered diagnostic failure.

For a variety of reasons, the patient’s perception of medical care differs profoundly from the clinician’s. Aside from the obvious differential of knowledge and power, there is the unavoidable fact that patients and families are the only individuals who traverse the entire spectrum of care and the only ones who experience first-hand the effects and outcomes of assessment and treatment. As is attested by a small but growing body of first person accounts by physician-patients, the reality of the patient experience often comes as a surprise to doctors, who assume, until they become patients themselves, that the system functions much more seamlessly than it does [1–4]. Patients, too, have a body of literature on their healthcare experiences [5–8]. Many of these accounts paint a less than flattering picture. A significant portion of the dissonance they record revolves around diagnosis: misdiagnosis, delay in diagnosis, failure to diagnose, and the many factors that contribute to these failures. Like doctors, patients are often taken by surprise by the fallibilities of the healthcare system, and even more by the system’s apparent lack of responsiveness to feedback from its users. Yet it should be evident that patient accounts, medicine’s reality check, have tremendous value. They hold the keys not just to detecting system errors but to improving diagnostic performance by providing a window onto the ways that recommendations are carried out, the ways information flows, and the ways that individual clinicians’ recommendations intersect with those of others. Above all, they can shed light on the aspects of the patientprovider equation that facilitate accurate diagnosis, and on the real-life effects on patients of diagnoses both accurate and inaccurate, timely and delayed. Over the course of what has become a second career in patient safety advocacy, I have heard many patient accounts of harm – and you only need hear a few to appreciate the repetition inherent in these stories. Among the most striking patterns are those of diagnostic error. These include systematic ways in which certain diagnoses are missed, pat conclusions that are substituted for clinical assessment when diagnoses are difficult, and delays in identification that can turn treatable conditions into crises. It is the persistence of these patterns that patients find so hard to comprehend; and it is the stories of these patterns that reveal the fault lines along which the system can give way, again and again. If ever there was a treasure to be found in complaints, this is it. Like most patient advocates, I came to the calling of patient safety through a story of my own – the loss of my brilliant young son to complications of elective surgery. And like most stories, his illustrates more than one of the patterns listed above [9]. Lewis was a healthy 15-year-old when we took him to the hospital for a procedure to correct a structural defect of the chest wall, pectus excavatum. While the surgery was hardly minor, we did not appreciate that it had a risk-benefit calculus that might not be appropriate for a child with a relatively mild defect (as Lewis’s was). It was not the surgery per se from which our son died, however, but the pain control regimen that accompanied it. Residents and nurses failed for over 30 hours to recognize signs of a perforated ulcer brought on by the NSAID painkiller ketorolac, which Lewis was given as an opioid-sparing adjunct to his epidural narcotics. Ironically, the wellknown NSAID side effect of gastric perforation was never considered, because residents and nurses focused immediately and unswervingly on the possibility of narcotic-induced ileus as an explanation for Lewis’s sudden, severe abdominal pain. Autopsy revealed the error. Our vibrant boy had not only suffered a giant duodenal ulcer and severe peritonitis; he had also lost more than half his blood as the ulcer eroded into the underlying artery. The signs of these conditions were blindingly obvious in retrospect. It was clear that the diagnosis of narcotic-related constipation was a poor fit with the 5-out-of-5 pain, weakness, and wildly deranged vital signs that Lewis had exhibited. Yet residents and nurses had been so sure of themselves that they had treated our requests for help as little more than

Marijuana use and risk of lung cancer: a 40-year cohort study

Cannabis (marijuana) smoke and tobacco smoke contain many of the same potent carcinogens, but a critical-yet unresolved-medical and public-health issue is whether cannabis smoking might facilitate the development of lung cancer. The current study aimed to assess the risk of lung cancer among young marijuana users. A population-based cohort study examined men (n = 49,321) aged 18-20 years old assessed for cannabis use and other relevant variables during military conscription in Sweden in 1969-1970. Participants were tracked until 2009 for incident lung cancer outcomes in nationwide linked medical registries. Cox regression modeling assessed relationships between cannabis smoking, measured at conscription, and the hazard of subsequently receiving a lung cancer diagnosis. At the baseline conscription assessment, 10.5 % (n = 5,156) reported lifetime use of marijuana and 1.7 % (n = 831) indicated lifetime use of more than 50 times, designated as "heavy" use. Cox regression analyses (n = 44,284) found that such "heavy" cannabis smoking was significantly associated with more than a twofold risk (hazard ratio 2.12, 95 % CI 1.08-4.14) of developing lung cancer over the 40-year follow-up period, even after statistical adjustment for baseline tobacco use, alcohol use, respiratory conditions, and socioeconomic status. Our primary finding provides initial longitudinal evidence that cannabis use might elevate the risk of lung cancer. In light of the widespread use of marijuana, especially among adolescents and young adults, our study provides important data for informing the risk-benefit calculus of marijuana smoking in medical, public-health, and drug-policy settings.