Cognitive biases in surgery: systematic review.

BACKGROUND: Although numerous studies have established cognitive biases as contributors to surgical adverse events, their prevalence and impact in surgery are unknown. This review aimed to describe types of cognitive bias in surgery, their impact on surgical performance and patient outcomes, their source, and the mitigation strategies used to reduce their effect. METHODS: A literature search was conducted on 9 April and 6 December 2021 using MEDLINE, Embase, PsycINFO, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Included studies investigated how cognitive biases affect surgery and the mitigation strategies used to combat their impact. The National Institutes of Health tools were used to assess study quality. Inductive thematic analysis was used to identify themes of cognitive bias impact on surgical performance. RESULTS: Thirty-nine studies were included, comprising 6514 surgeons and over 200 000 patients. Thirty-one types of cognitive bias were identified, with overconfidence, anchoring, and confirmation bias the most common. Cognitive biases differentially influenced six themes of surgical performance. For example, overconfidence bias associated with inaccurate perceptions of ability, whereas anchoring bias associated with inaccurate risk-benefit estimations and not considering alternative options. Anchoring and confirmation biases associated with actual patient harm, such as never events. No studies investigated cognitive bias source or mitigation strategies. CONCLUSION: Cognitive biases have a negative impact on surgical performance and patient outcomes across all points of surgical care. This review highlights the scarcity of research investigating the sources that give rise to cognitive biases in surgery and the mitigation strategies that target these factors.

Gastric or duodenal perforation and secondary septic peritonitis following therapeutic nonsteroidal anti-inflammatory drug administration.

OBJECTIVE: To report which nonsteroidal anti-inflammatory drugs (NSAIDs) were associated with gastric or duodenal perforation (GDP) in dogs presented to a university teaching hospital and to report the frequency of prescription of NSAIDs by the corresponding referring veterinary community during the same time period. DESIGN: Retrospective cohort study of dogs from January 2007 to March 2020. SETTING: Single university teaching hospital. ANIMALS: A total of 30 dogs met inclusion criteria. MEASUREMENTS AND MAIN RESULTS: Four dogs were administered more than 1 NSAID within 7 days of GDP, 3 dogs received a combination of an NSAID and a corticosteroid, and 1 dog received 2 NSAIDs and a corticosteroid. Four dogs received an overdose of an NSAID. One dog received an overdose of 1 NSAID and received an additional NSAID at the labeled dose within 7 days of GDP. Eighteen dogs received only 1 NSAID at the labeled dose. In these 18 dogs, meloxicam was administered in 44.4% (8/18), firocoxib in 27.8% (5/18), deracoxib in 16.7% (3/18), and piroxicam in 11.1% (2/18). One hundred and sixty surveys on NSAID prescribing practice were returned. Carprofen was the most commonly prescribed NSAID (70.6%), followed by meloxicam (10.6%), deracoxib (8.4%), firocoxib (7.8%), aspirin (1.5%), and other (0.9%). CONCLUSIONS: NSAID administration, even at labeled doses, appears to be a precipitating factor for GDP. Despite carprofen being the most frequently prescribed NSAID over the study period, no case of GDP received it as a single therapeutic agent. Further prospective evaluation is needed to verify these findings.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

BACKGROUND: Despite being implemented for over a decade, literature describing how the surgical safety checklist (SSC) is completed by operating room (OR) teams and how this relates to its effectiveness is scarce. This systematic review aimed to: (1) quantify how many studies reported SSC completion versus described how the SSC was completed; (2) evaluate the impact of the SSC on provider outcomes (Communication, case Understanding, Safety Culture, CUSC), patient outcomes (complications, mortality rates) and moderators of these relationships. METHODS: A systematic literature search was conducted using Medline, CINAHL, Embase, PsycINFO, PubMed, Scopus and Web of Science on 10 January 2020. We included providers who treat human patients and completed any type of SSC in any OR or simulation centre. Statistical directional findings were extracted for provider and patient outcomes and key factors (eg, attentiveness) were used to determine moderating effects. RESULTS: 300 studies were included in the analysis comprising over 7 302 674 operations and 2 480 748 providers and patients. Thirty-eight per cent of studies provided at least some description of how the SSC was completed. Of the studies that described SSC completion, a clearer positive relationship was observed concerning the SSC's influence on provider outcomes (CUSC) compared with patient outcomes (complications and mortality), as well as related moderators. CONCLUSION: There is a scarcity of research that examines how the SSC is completed and how this influences safety outcomes. Examining how a checklist is completed is critical for understanding why the checklist is successful in some instances and not others.

Adjuvant Chemotherapy With or Without Biologics Including Antiangiogenics and Monoclonal Antibodies Targeting EGFR and EpCAM in Colorectal Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: Adjuvant therapy for early-stage colorectal cancer improves survival. Biologic agents have shown promise as adjuncts to chemotherapy in metastatic colon cancer, but the effect on earlier stage cancer remains unclear. MATERIALS AND METHODS: We conducted a systematic review and meta-analysis of the additive effect of biologic agents to adjuvant chemotherapy on survival in colorectal cancer (all comers and subpopulations defined by microsatellite instability, BRAF and KRAS status, and stage). Only randomized controlled trials published between 2002 and 2017 in MEDLINE, EMBASE, and CENTRAL were included. The control arm: chemotherapy alone, the intervention arm: chemotherapy with biologic agents. OUTCOMES: overall survival (OS) and disease-free survival. RESULTS: Six trials including 10,754 patients were included. OS (hazard ratio [HR] 2.55, 95% confidence interval [CI] 2.15-3.03) and disease-free survival (HR 2.54, 95% CI 2.25-2.87) were significantly worse in the intervention arm. High heterogeneity was explained by subgroup analysis of different biologic agents (bevacizumab versus others); however, results still showed harm in the intervention arm across subgroups. Bevacizumab was associated with improved OS in patients with microsatellite instability (HR 0.58, 95% CI 0.36-0.92); this was the only indication of benefit for a biomarker-defined subpopulation. Analyses by tumor stage failed to demonstrate advantage with use of a biologic agent; however, it explained heterogeneity. CONCLUSIONS: The addition of biologic agents to adjuvant chemotherapy in the treatment of high-risk stage II and III colorectal cancer is associated with worse survival outcomes. The only subgroup of patients that may benefit from the addition of bevacizumab to adjuvant chemotherapy is those with microsatellite unstable tumors.

Antibiotic resistant bacteria are widespread in songbirds across rural and urban environments.

The widespread use of antibiotics in human and veterinary medicine to treat pathogenic bacteria has resulted in the rapid emergence of antibiotic-resistant bacteria (ARB). Wild animals may enable the spread of pathogenic and non-pathogenic ARB when they are exposed to reservoirs (e.g., contaminated soil, water, or crops) and carry ARB in and on their bodies to other environments. We tested for the presence of ARB in four songbird species in southwest Michigan across a gradient of land use. Our specific objectives were to: 1) quantify the prevalence of ARB found in the gut microbiome of birds; 2) identify the specific bacteria exhibiting resistance; 3) assess whether ARB prevalence and identity varied among bird species; and 4) assess whether anthropogenic land use influenced the prevalence and identity of ARB found on birds. We sampled birds across a land use gradient consisting of urban, agricultural, and natural land covers using a randomized, spatially-balanced sampling design and cultured bacteria from fecal samples in the presence of three different antibiotics (amoxicillin, tetracycline, and ciprofloxacin). Overall prevalence of ARB was high, with 88% of total birds carrying ARB resistant to one of three antibiotics that we tested. Resistance to amoxicillin was more common (83% of sampled birds) than resistance to tetracycline (15%) or ciprofloxacin (1%). Identified ARB were diverse, and included 135 isolates representing 5 bacterial phyla and 22 genera. There was no effect of land use on ARB prevalence, with 90% of sampled birds captured in rural sites and 85% of sampled birds in urban sites carrying ARB. We provide the first analysis of ARB prevalence across multiple bird species and land uses utilizing a spatially-balanced, randomized study design. Our results demonstrate that nearly all sampled birds carried at least some ARB, and that they may serve as important dispersal agents of ARB across large spatial scales.

Cognate Costs in Bilingual Speech Production: Evidence from Language Switching.

This study investigates cross-language lexical competition in the bilingual mental lexicon. It provides evidence for the occurrence of inhibition as well as the commonly reported facilitation during the production of cognates (words with similar phonological form and meaning in two languages) in a mixed picture naming task by highly proficient Welsh-English bilinguals. Previous studies have typically found cognate facilitation. It has previously been proposed (with respect to non-cognates) that cross-language inhibition is limited to low-proficient bilinguals; therefore, we tested highly proficient, early bilinguals. In a mixed naming experiment (i.e., picture naming with language switching), 48 highly proficient, early Welsh-English bilinguals named pictures in Welsh and English, including cognate and non-cognate targets. Participants were English-dominant, Welsh-dominant, or had equal language dominance. The results showed evidence for cognate inhibition in two ways. First, both facilitation and inhibition were found on the cognate trials themselves, compared to non-cognate controls, modulated by the participants' language dominance. The English-dominant group showed cognate inhibition when naming in Welsh (and no difference between cognates and controls when naming in English), and the Welsh-dominant and equal dominance groups generally showed cognate facilitation. Second, cognate inhibition was found as a behavioral adaptation effect, with slower naming for non-cognate filler words in trials after cognates than after non-cognate controls. This effect was consistent across all language dominance groups and both target languages, suggesting that cognate production involved cognitive control even if this was not measurable in the cognate trials themselves. Finally, the results replicated patterns of symmetrical switch costs, as commonly reported for balanced bilinguals. We propose that cognate processing might be affected by two different processes, namely competition at the lexical-semantic level and facilitation at the word form level, and that facilitation at the word form level might (sometimes) outweigh any effects of inhibition at the lemma level. In sum, this study provides evidence that cognate naming can cause costs in addition to benefits. The finding of cognate inhibition, particularly for the highly proficient bilinguals tested, provides strong evidence for the occurrence of lexical competition across languages in the bilingual mental lexicon.

Biopsychosocial determinants of treatment outcome for mood and anxiety disorders up to 8 months postpartum.

Little is known about the biopsychosocial determinants that predict postpartum treatment outcome for mood and anxiety disorders. Postpartum mood and anxiety symptoms and psychosocial/biological variables were recorded for 8 months of 22 women treated with antidepressants during pregnancy. Depression scores decreased by 58%, whereas anxiety scores decreased by 35%. Family history of psychiatric illness and prior psychiatric illness unrelated to pregnancy predicted depressive treatment outcome, and sexual abuse history and prior psychiatric illness unrelated to pregnancy predicted anxiety outcome. Biological and psychosocial variables predicted pharmacological treatment outcome in postpartum-depressed and anxious women.

Luteal phase administration of paroxetine for the treatment of premenstrual dysphoric disorder: a randomized, double-blind, placebo-controlled trial in Canadian women.

OBJECTIVE: To evaluate the efficacy and safety of intermittent, luteal phase-only administration of paroxetine (10 mg and 20 mg) in the treatment of premenstrual dysphoric disorder (PMDD). METHOD: In this multicenter trial, female outpatients (aged 18-45 years) from 4 Canadian health centers meeting DSM-IV criteria for PMDD were asked to perform daily ratings of their premenstrual symptoms for 2 consecutive menstrual cycles. Those displaying the symptoms of irritability and/or depressed mood in the luteal phases but not in the follicular phases of their menstrual cycles were randomly assigned to intermittent, luteal phase-only treatment with paroxetine 10 mg or 20 mg or placebo for 4 additional cycles. The primary efficacy endpoint was the percent change from baseline at study endpoint on the visual analog scale irritability score. Treatment differences were tested using analysis of covariance ad hoc. Estimated treatment mean differences and their associated 95% confidence intervals were also calculated. Data were collected from May 1999 to November 2002. RESULTS: Ninety-nine patients were included in the intention-to-treat population. When compared with placebo, patients treated with paroxetine 20 mg attained a significant reduction in irritability (difference in median percent change: -23.9, 95% CI = -51.3 to -6.2, p = .014; difference in mean absolute change: -18.6, 95% CI = -32.5 to -4.6, p = .007). A statistically significant difference was not observed when the patients treated with the lower dose of paroxetine (10 mg) were compared with placebo. Treatment was well tolerated with no unexpected side effects. CONCLUSIONS: Intermittent administration of paroxetine 20 mg significantly reduced irritability symptoms in patients with PMDD. These results are consistent with previous studies suggesting that PMDD may be treated effectively by luteal phase-only administration of a selective serotonin reuptake inhibitor. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00620581.

Psychologic aspects of early pregnancy loss.

Early pregnancy loss is a complicated psychologic event that occurs in 12% to 24% of recognized pregnancies. Women who have experienced miscarriage often have common bereavement reactions and while the intensity and experience of these reactions diminishes over time for most women, a substantial minority will develop long-term psychiatric consequences. Depression, symptoms of anxiety, obsessive-compulsive disorder, and posttraumatic stress disorder are the most commonly reported psychologic reactions to miscarriage. The course and impact of these disorders on a grieving mother and her partner are discussed and treatment recommendations are made. The psychologic effects of therapeutic abortion are also be briefly discussed.

Internalizing behaviors in 4-year-old children exposed in utero to psychotropic medications.

OBJECTIVE: Internalizing behaviors in children between 4 and 5 years of age who had been prenatally exposed to psychotropic medications were investigated. The authors had previously reported the effects of prenatal medication exposure in this same cohort when they were newborns and infants at 3 and 8 months of age. METHOD: Parental/teacher reports and a clinical measure of mother and child interactions were used to assess levels of internalizing behaviors (e.g., depression, anxiety, withdrawal). Outcomes were compared between children with prenatal selective serotonin reuptake inhibitor (SSRI) exposure (N=22) and nonexposed children of healthy, nondepressed, nonmedicated mothers (N=14). Measures of maternal mood were obtained. Ordered logistic regressions, independent-sample t tests, and univariate ANOVAs were used to compare outcomes between groups. Pearson correlations were used to determine associations between maternal mood and child behaviors. RESULTS: Levels of internalizing behaviors did not differ significantly between children with prenatal psychotropic medication exposure and those not exposed. However, as symptoms of maternal anxiety and depression increased, so did reported internalizing behaviors in their children. CONCLUSIONS: Prenatal exposure to psychotropic medications was not associated with increased reports of internalizing behaviors at 4 years of age, whereas impaired maternal mood did have an identified impact on child behavior. Further study of complex associations between maternal psychiatric disorders, prenatal SSRI exposure, and childhood internalizing behaviors is required to understand if the child outcome is affected by the illness, medications, or a combination of both.

Assessment of sexual drive and desire in women with premenstrual dysphoric disorder who have been treated with fluoxetine.

Objective To explore the impact of treatment with fluoxetine on sexual drive and desire (SDD) in women with premenstrual dysphoric disorder (PMDD). Methods Data were collected during a randomised, controlled, double-blind trial evaluating the efficacy of fluoxetine 20 or 60 mg/day versus placebo in the treatment of women with PMDD. Study subjects rated their SDD on the Premenstrual Tension Scale, Self Rating (PMTS-SR) during their follicular and luteal phases of the placebo run in cycles and the double-blind treatment cycles. Data were analyzed using chi-square test. Results Data were available for 184 subjects who rated their SDD during the follicular and luteal phases of two baseline (placebo) cycles and the following two treatment cycles. There was a trend for more women on fluoxetine to report improvement in luteal phase SDD compared to women on placebo (P=0.057). Conclusions Our data, contrary to expectations, suggest that fluoxetine treatment may restore SDD in women who experience decreased SDD as part of a cluster of symptoms associated with PMDD. Future trials with SSRIs should include specific measures of sexual functioning to further examine the potential beneficial versus side effects of these medications as they relate to phases of the menstrual cycle.

The value of role modelling: Perceptions of undergraduate and diploma nursing (adult) students.

Using a grounded theory methodology, this paper demonstrates the value of role modelling in teaching and learning within the clinical area. Views of undergraduate (n=20) and diploma (n=22) nursing (adult) students were sought using individual and focus group interviews. Although the importance of role modelling is acknowledged within the literature, there appears to be little written about the value of providing role modelling within the clinical learning environment to facilitate learning for student nurses. Both groups of students stated the importance of having access to a good role model in order that they could observe and practice skills and/or behaviour. 'Good' role models were seen to have a tremendous influence on the clinical learning environment and on the development of students' competence and confidence. Recommendations were made to include discussions on the value of role modelling on enhancing the clinical learning environment within mentor preparation courses. These discussions should emphasise the value of observational learning, the necessity of providing constructive feedback and the need for role models to enable the student to convert observed behaviour/skills into their own behaviour and skills set.

Relation between prenatal maternal mood and anxiety and neonatal health.

OBJECTIVE: To examine the relation between the mood and anxiety of pregnant, psychiatrically treated women and neonatal health outcomes after birth. METHOD: We prospectively assessed 46 women treated with psychotropic medications for anxiety and depression during pregnancy. We compared measures of maternal mental health with infant outcomes, in particular, the outcomes of infants with symptoms of poor neonatal adaptation. RESULTS: The mothers of babies who demonstrated poor neonatal adaptation reported higher levels of anxiety and depression at study entry than did the mothers of healthy babies. This relation was not related to the presence or absence of treatment with clonazepam, an anxiolytic used to treat symptoms of anxiety. Further, increased psychiatric comorbidity in the mother was associated with a greater likelihood of transient symptoms in the newborn. CONCLUSIONS: Despite psychiatric treatment, the intensity and degree of comorbid symptoms appear to be related to poor transient neonatal health outcome. Our data suggest that, in addition to the impact of pharmacologic factors, maternal psychiatric status influences infant outcomes.

A controlled study of postpartum depression among Nepalese women: validation of the Edinburgh Postpartum Depression Scale in Kathmandu.

OBJECTIVES: To measure the prevalence of depression amongst postpartum and non-postpartum Nepalese women in Kathmandu using the Edinburgh Postpartum Depression Scale (EPDS) and to assess the ease of use and validity of the scale compared with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for major depression. METHODS: We screened 100 women 2-3 months post-delivery and 40 control women using the EPDS. All those who screened positive for depression and 20% of the negatives also underwent a structured interview to assess depression by DSM-IV criteria. RESULTS: Predictive errors were minimized by using an EPDS score > or =13 to define depression. Using this threshold, there was no difference in depression prevalence between postpartum women (12%) and the control group (12.5%) (Fisher's exact test, P > 0.05). Compared with DSM-IV, the sensitivity, specificity and positive predictive values were 100, 92.6 and 41.6%, respectively. CONCLUSIONS: The prevalence of postpartum depression (PPD) in Nepalese women and the validity and ease of use of the EPDS in the setting of a postnatal clinic in Kathmandu are all surprisingly similar to the results of numerous studies in developed countries. Despite poor living conditions, PPD is no more common than the background depression rate amongst Nepalese women. It can be reliably detected by trained clinical nurses using the EPDS screening test. These results may have implications for the planning of mental health resources for women in other developing countries.

Welfare benefits' screening and referral: a new direction for community nurses?

The White Paper, Towards a Healthier Scotland considerably widens the community nursing scope for health promotion, as it recognises that disadvantaged life circumstances as well as unhealthy lifestyles contribute to poor health. It has been shown that income and health are interrelated. This evidence has demonstrated that it is not how rich a nation is that determines the overall health of its inhabitants; it is how equitably its wealth is distributed that counts: countries that have narrow income differentials tend to have better health. Both the income and health divide in Britain widened considerably between 1980 and 1992. It is argued that increasing income inequality leads to social isolation and chronic stress, which can impact on psycho-social pathways and damages life expectancy. This paper suggests that community nurses can address adverse life circumstances by finding ways of improving the economic status of their most vulnerable clients, and that one way of doing this would be to ensure that clients claim their full quota of welfare entitlement, given that there is several billion pounds of social security benefits that remain unclaimed in Britain every year.