Decision-making in Orthopaedic Oncology: Does Cognitive Bias Affect a Virtual Patient's Choice Between Limb Salvage and Amputation?

BACKGROUND: The local treatment of extremity sarcomas usually is predicated on a decision between limb salvage and amputation. The manner in which surgical options are presented in the context of shared decision-making may influence this decision. In a population of "simulated" patients-survey respondents presented with a mock clinical vignette and then asked to choose between treatments-we assessed cognitive bias by deliberate alteration of the subjective presentation of the same objective information. QUESTIONS/PURPOSES: (1) Will the manner in which information is presented to a simulated patient, in the setting of treatment for a bone sarcoma, bias their decision regarding pursuing amputation versus limb salvage? (2) At the time of decision-making, will a simulated patient's personal background, demographics, or mood affect their ultimate decision? METHODS: Survey respondents (Amazon MTurk platform) were presented with mock clinical vignettes simulating a sarcoma diagnosis and were asked to choose between amputation and limb salvage. Specific iterations were designed to assess several described types of cognitive bias. These scenarios were distributed, using anonymous online surveys, to potential participants aged 18 years or older. Recruitment was geographically restricted to individuals in the United States. Overall, 404 respondents completed the survey. The average age of respondents was 33 years (SD 1.2 years), 60% were male and 40% were female. In all, 12% of respondents worked in healthcare. Each respondent also completed questions regarding his or her demographics and his or her current mood. Associations between the type of bias presented and the respondent's choice of limb salvage versus amputation were examined. Independent sample t-tests were used to compare means. Statistical significance was defined as p < 0.05. RESULTS: When amputation was presented as an option to mitigate functional loss (framing bias), more patients chose it than when limb salvage was presented as means for increased functional gains (23% [23 of 100] versus 10% [12 of 118], odds ratio [OR], 2.26; p = 0.010). Older simulated patients were more likely to choose limb salvage when exposed to framing bias versus younger patients (mean age 33 years versus 30 years, p = 0.02). Respondents who were employed in healthcare more commonly chose amputation versus limb salvage when exposed to framing bias (24% [eight of 35] versus 9% [17 of 183]; OR, 2.46; p = 0.02). Those who chose amputation were more likely to score higher on scales that measured depression or negative affect. CONCLUSIONS: Shared decision-making in orthopaedic oncology represents a unique circumstance in which several variables may influence a patient's decision between limb salvage and amputation. Invoking cognitive bias in simulated patients appeared to affect treatment decisions. We cannot be sure that these findings translate to the experience of actual sarcoma patients; however, we can conclude that important treatment decisions may be affected by cognitive bias and that patient characteristics (in this study, age, healthcare profession, and mood) may be associated with an individual's susceptibility to cognitive bias. We hope these observations will assist providers in the thoughtful delivery of highly charged information to patients facing difficult decisions, and promote further study of this important concept. LEVEL OF EVIDENCE: Level III, economic and decision analyses.

The depressogenic potential of added dietary sugars.

Added sugars are ubiquitous in contemporary Western diets. Although excessive sugar consumption is now robustly associated with an array of adverse health consequences, comparatively little research has thus far addressed its impact on the risk of mental illness. But ample evidence suggests that high-dose sugar intake can perturb numerous metabolic, inflammatory, and neurobiological processes. Many such effects are of particular relevance to the onset and maintenance of depressive illness, among them: systemic inflammation, gut microbiota disruption, perturbed dopaminergic reward signaling, insulin resistance, oxidative stress, and the generation of toxic advanced glycation end-products (AGEs). Accordingly, we hypothesize that added dietary sugars carry the potential to increase vulnerability to major depressive disorder, particularly at high levels of consumption. The present paper: (a) summarizes the existing experimental and epidemiological research regarding sugar consumption and depression vulnerability; (b) examines the impact of sugar ingestion on known depressogenic physiological processes; and (c) outlines the clinical and theoretical implications of the apparent sugar-depression link. We conclude that the extant literature supports the hypothesized depressogenic impact of added dietary sugars, and propose that an improved understanding of the effects of sugar on body and mind may aid in the development of novel therapeutic and preventative measures for depression.

A preliminary review of the Beck Depression Inventory-II (BDI-II) in veterans: Are new norms and cut scores needed?

The Beck Depression Inventory-II (BDI-II) is used within the Veterans Health Administration (VHA) to measure depression symptom severity. This naturalistic study aimed to examine VHA-specific BDI-II use and establish normative data and psychometric properties. Initial BDI-II data for 152,260 individual veterans were extracted from preexisting medical records using the VA Informatics and Computing Infrastructure. BDI-II scores were compared against Beck, Steer, and Brown (1996)'s original sample, as well as across veteran subgroups. Exploratory and confirmatory factor analyses were also conducted. Similar to Beck et al.'s (1996) sample, the BDI-II was most frequently administered in outpatient psychiatric VHA settings, although it was also used in inpatient and medical settings. Veterans scored significantly higher on the BDI-II than the original comparison groups. This was true across diagnostic categories. The largest discrepancy was seen between nondepressed veterans and corresponding patients from the original sample (Cohen's d = 1.34). Older veterans endorsed less severe levels of depression symptomatology. Additionally, a 2-factor model similar to Beck et al.'s (1996) original solution provided the best fit to the data. Veterans reported higher levels of somatic-affective symptoms than cognitive symptoms. Although potentially useful, the BDI-II requires further investigation in veterans. Standard cut scores are not recommended for use in this population when evaluating severity of depression. A cut score of 27 or higher best differentiated between veterans with and without mood disorders in the current sample. Treatment providers should also consider using BDI-II factor scores, rather than the total score, to measure depressive symptom change. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Seroepidemiology of Bartonella infection in gray foxes from Texas.

Gray foxes (Urocyon cinereoargenteus) were shown to be naturally infected with Bartonella rochalimae, a Bartonella species similar to Bartonella clarridgeiae (B.c.), and Bartonella vinsonii subspecies berkhoffii (B.v.berkhoffii) in northern California. A serological survey was performed to investigate the presence of Bartonella infection in 132 gray foxes from West/Central Texas. Using an immunofluorescence antibody test directed against B.v.berkhoffii and B.c., the antibody prevalence was 50% (66/132), with 22 (33.3%) individuals seropositive for B.c. only, 8 (12.2%) for B.v.berkhoffii, and 36 (54.5%) seroreactive for both B.c. and B.v.berkhoffii. The foxes had 3.63 more odds (95% confidence interval [CI]=1.38, 10.25) to be seropositive for B.c. than for B.v.berkhoffii. Female foxes were more likely to be seropositive for B.c. (odds ratio [OR]=2.90, 95% CI=1.33, 6.36) and also for both antigens (OR=2.50, 95% CI=1.06, 5.90) than males.

Seroprevalence of Bartonella spp. in the endangered island fox (Urocyon littoralis).

Bartonella clarridgeiae-like strains, presently B. rochalimae, were isolated in gray foxes (Urocyon cinereoargenteus) in mainland California. The objective of this study was to investigate the presence of Bartonella infection in the endangered island fox (Urocyon littoralis) found only on the Channel Islands off the Californian coast. Between 2001 and 2004, 263 serum samples were collected. Antibodies against Bartonella vinsonii subsp. berkhoffii (Bvb) and B. clarridgeiae (Bc) were detected using an immuno-fluorescence antibody test. Sixty-eight (25.8%) and 73 (27.7%) foxes were positive for Bvb and Bc, respectively. Seroprevalence was the highest on Santa Cruz Island (n=36, Bvb=80.5%; Bc=86.1%) and Santa Rosa Island (n=38, Bvb=52.6%; Bc=65.8%). On San Miguel and San Clemente Islands, seroprevalence for Bvb was 20% and 17.3% respectively, and 0% and 21.3% for Bc. Prevalence ranged between 0% and 5.1% on San Nicolas and Santa Catalina Islands. Foxes from Santa Rosa and Santa Cruz Islands were 17.5 times and 31.5 times as likely to be seropositive for Bvb and Bc than foxes from the other islands (95% confidence interval [95% CI]=8.5, 36.7; 14.4, 70.2). There were no statistically significant differences for presence of Bartonella antibodies by sex, age, origin (captive vs. wild) or year of blood collection. This is the first report of exposure to Bartonella in the island fox population. Further studies are necessary to isolate these bacteria from foxes and determine factors associated with presence or absence of Bartonella species on specific islands.