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Objective: Clinical options for managing nonmetastatic prostate cancer (PCa) vary. Each option has side effects associated with it, leading to difficulty in decision‐making. This study aimed to assess the relationship between patient involvement in treatment decision‐making and subsequent decision regret (DR), and quantify the impact of health‐related quality of life (HRQL) outcomes on DR. Methods: Men living in the United Kingdom, 18 to 42 months after diagnosis of PCa, were identified from cancer registration data and sent a questionnaire. Measures included the Decision Regret Scale (DRS), Expanded Prostate cancer Index Composite short form (EPIC‐26), EQ‐5D‐5L, and an item on involvement in treatment decision‐making. Multivariable ordinal regression was utilized, with DR categorized as none, mild, or moderate/severe regret. Results: A total of 17 193 men with stage I‐III PCa completed the DRS: 36.6% reported no regret, 43.3% mild regret, and 20.0% moderate/severe regret. The odds of reporting DR were greater if men indicated their views were not taken into account odds ratio ([OR] = 6.42, 95% CI: 5.39‐7.64) or were involved “to some extent” in decision‐making (OR = 4.63, 95% CI: 4.27‐5.02), compared with men who were “definitely” involved. After adjustment, including for involvement, men reporting moderate/big problems with urinary, bowel, or sexual function were more likely to experience regret compared with men with no/small problems. Better HRQL scores were associated with lower levels of DR. Conclusions: This large‐scale study demonstrates the benefit of patient involvement in treatment decision‐making for nonmetastatic PCa. However, men experiencing side effects and poorer HRQL report greater DR. Promoting engagement in clinical decision‐making represents good practice and may reduce the risk of subsequent regret.

ObjectiveIncreased knowledge of breast cancer risk factors enables a shift from one‐size‐fits‐all breast cancer screening to a risk‐based approach, tailoring screening policy to a woman's individual risk. New opportunities for prevention will arise. However, before this novel screening and prevention program is introduced, its acceptability from a woman's perspective needs to be explored.MethodsWomen eligible for breast cancer screening in the Netherlands, United Kingdom, and Sweden were invited to take part in focus groups. A total of 143 women participated. Data were transcribed verbatim and analyzed using thematic analysis.ResultsAnalysis identified five themes across the three countries. The first theme “impact of knowledge” describes women's concern of not being able to unlearn their risk, perceiving it as either a motivator for change or a burden which may lead to stigma. The second theme “belief in science” explains women's need to trust the science behind the risk assessment and subsequent care pathways. Theme three “emotional impact” explores, eg, women's perceived anxiety and (false) reassurance, which may result from knowing their risk. Theme four “decision making” highlights cultural differences in shared versus individual decision making. Theme five “attitude to medication” explores the controversial topic of offering preventative medication for breast cancer risk reduction.ConclusionsAcceptability of risk‐based screening and prevention is mixed. Women's perceptions are informed by a lack of knowledge, cultural norms, and common emotional concerns, which highlights the importance of tailored educational materials and risk counselling to aid either shared or individual informed decision making.

Adolescents aspire for independence. Successful independence means knowing when to rely on one's own knowledge and when to listen to others. A critical prerequisite thus is a well‐developed metacognitive ability to accurately assess the quality of one's own knowledge. Little is known about whether the strive to become an independent decision maker in adolescence is underpinned by the necessary metacognitive skills. Here, we demonstrate that metacognition matures from childhood to adolescence (N = 107) and that this process coincides with greater independent decision‐making. We show that adolescents, in contrast to children, take on others’ advice less often, but only when the advice is misleading. Finally, we demonstrate that adolescents’ reduced reliance on others’ advice is explained by their increased metacognitive skills, suggesting that a developing ability to introspect may support independent decision‐making in adolescence., Moses‐Payne et al investigated how advice taking develops during childhood and adolescence, and how this is related to metacognition. Children, 8‐9 year olds (yo), and two groups of adolescents, 12‐13 year olds and 16‐17 year olds, took part in a metacognition and advice taking task. Both adolescent groups showed increased ability to identify when they were correct or incorrect (increased metacognitive efficiency, Panel A). The adolescent groups also showed a lower propensity to follow advice than children (Panel B). Importantly, adolescents were less likely to follow false advice but still followed helpful advice (Panel C). In this way, adolescents were more competent advice takers, and this was linked to their metacognitive abilities: resistance to false advice was driven by adolescents' increased metacognitive efficiency (Panel D). The adolescents utilized their new‐found metacognitive abilities to resist false advice from others when they knew they were correct, but still took helpful advice when they knew they were incorrect.

Forensic pathologists’ decisions are critical in police investigations and court proceedings as they determine whether an unnatural death of a young child was an accident or homicide. Does cognitive bias affect forensic pathologists’ decision‐making? To address this question, we examined all death certificates issued during a 10‐year period in the State of Nevada in the United States for children under the age of six. We also conducted an experiment with 133 forensic pathologists in which we tested whether knowledge of irrelevant non‐medical information that should have no bearing on forensic pathologists’ decisions influenced their manner of death determinations. The dataset of death certificates indicated that forensic pathologists were more likely to rule "homicide" rather than "accident" for deaths of Black children relative to White children. This may arise because the base‐rate expectation creates an a priori cognitive bias to rule that Black children died as a result of homicide, which then perpetuates itself. Corroborating this explanation, the experimental data with the 133 forensic pathologists exhibited biased decisions when given identical medical information but different irrelevant non‐medical information about the race of the child and who was the caregiver who brought them to the hospital. These findings together demonstrate how extraneous information can result in cognitive bias in forensic pathology decision‐making.

ObjectiveAccording to the precaution adoption process model, cervical screening nonparticipants represent a heterogeneous group including those who are unaware of, unengaged with, or undecided about screening, as well as intenders and decliners. We aimed to explore beliefs about cervical screening among these different types of nonparticipant.MethodsSemistructured interviews were carried out with women aged 26 to 65 years living in Britain (n = 29). Women were purposively sampled to represent different nonparticipant types. Interviews were transcribed verbatim, and data were analysed thematically using framework analysis.ResultsThe salience of some barriers to screening varied between different types of nonparticipant. Bad experiences were prominent in the discussions of women who had decided not to attend, while practical barriers were more prominent among intenders. There was also some overlap between nonparticipant types. For example, many of the undecided women described not wanting to go for screening, but with less certainty than decliners. Some intenders (particularly those who had not been screened before) described not really wanting to attend but feeling they ought to. Women's views on the invitation/reminder process also varied; intenders and maintainers appreciated written reminders and general practitioner (GP) prompts but decliners sometimes perceived these as “badgering.” Throughout the interviews, women described changing views on screening in the wider context of ageing and motherhood.ConclusionsThe salience of screening barriers varies by nonparticipant type, offering possibilities for tailored interventions. However, the fluidity of women's stage of screening adoption might have implications for this approach to intervention design.

Temporal and spatial patterns of variability in aquatic ecosystems can be complex and difficult to quantify or predict. However, understanding this variability is critical to making a wide range of water quality assessment and management decisions effectively. Here we report on the nature and magnitude of spatial and temporal variation observed in conductivity, total phosphorus, and total nitrogen during a 15-year study of four U.S. stream systems receiving pulp and paper mill effluent discharges. Sampling locations included mainstem sites upstream and downstream of effluent discharge, as well as tributary sites. In all four stream systems, variability in conductivity as measured by the coefficient of variation was typically in the range of 10-50%, and was as low or lower than the variability in nutrient endpoints. The effect of effluent discharge was relatively minor overall, except in some site-specific instances. Some relatively large differences between tributary and mainstem variability were also observed. Flow variation tended to have a more consistent and larger effect on conductivity variation compared to the nutrient endpoints. After removing flow effects, significant relatively complex trends over time were observed at several sites. Changes in variability during the study also were observed. This paper highlights the importance of long-term studies to accurately characterize water quality variability used in water quality management decision-making.

Many everyday actions are implicit gambles because imprecisions in our visuomotor systems place probabilities on our success or failure. Choosing optimal action strategies involves weighting the costs and gains of potential outcomes by their corresponding probabilities, and requires stable representations of one's own imprecisions. How this ability is acquired during development in childhood when visuomotor skills change drastically is unknown. In a rewarded rapid reaching task, 6‐ to 11‐year‐old children followed ‘risk‐seeking’ strategies leading to overly high point‐loss. Adults' performance, in contrast, was close to optimal. Children's errors were not explained by distorted estimates of value or probability, but may reflect different action selection criteria or immature integration of value and probability information while planning movements. These findings provide a starting point for understanding children's risk‐taking in everyday visuomotor situations when suboptimal choices can be dangerous. Moreover, children's risky visuomotor decisions mirror those reported for non‐motor gambles, raising the possibility that common processes underlie development across decision‐making domains.

Objective Surgery is the mainstay of treatment for breast cancer. However, there is evidence that older women are not receiving this treatment. This study explores reasons why older women are not having surgery. Methods Twenty eight in‐depth interviews were conducted with women over 70 years old with operable breast cancer receiving primary endocrine therapy (PET) as their primary treatment. The interviews focused on their perceptions of why they were being treated with PET rather than surgery. Transcripts were analysed using the Framework method. Results Based on reasons for PET, patients were divided into three groups: ‘Patient Declined’, ‘Patient Considered’ or ‘Surgeon Decided’. The first group ‘Patient Declined’ absolutely ruled out surgery to treat their breast cancer. These patients were not interested in maximising their survival and rejected surgery citing their age or concerns about impact of treatment on their level of functioning. The second group ‘Patient Considered’ considered surgery but chose to have PET most specifying if PET failed then they could have the operation. Patients viewed this as offering them two options of treatment. The third group ‘Surgeon Decided’ was started by the surgeon on PET. These patients had comorbidities and in most cases the surgeon asserted that the comorbidities were incompatible with surgery. Conclusions Older women represent a diverse group and have multifaceted reasons for foregoing surgery. Discussions about breast cancer treatment should be patient centred and adapted to differing patient priorities. © 2015 The Authors. Psycho‐Oncology published by John Wiley & Sons Ltd.

Background: Counterfactuals are mental representations of alternatives to past events. Recent research has shown them to be important for other cognitive processes, such as planning, causal reasoning, problem solving, and decision making—all processes independently linked to the frontal lobes. Objective: To test the hypothesis that counterfactual thinking is impaired in some patients with Parkinson’s disease and is linked to frontal dysfunction in these patients. Methods. Measures of counterfactual processing and frontal lobe functioning were administered to 24 persons with Parkinson’s disease and 15 age matched healthy controls. Results. Patients with Parkinson’s disease spontaneously generated significantly fewer counterfactuals than controls despite showing no differences from controls on a semantic fluency test; they also performed at chance levels on a counterfactual inference test, while age matched controls performed above chance levels on this test. Performance on both the counterfactual generation and inference tests correlated significantly with performance on two tests traditionally linked to frontal lobe functioning (Stroop colour–word interference and Tower of London planning tasks) and one test of pragmatic social communication skills. Conclusions: Counterfactual thinking is impaired in Parkinson’s disease. This impairment may be related to frontal lobe dysfunction.

To examine the influence of evidence-based guidance on health care decisions, a study of the use of seven different sources and types of evidence-based guidance was carried out in senior health professionals in England with responsibilities either for directing and purchasing health care based in the health authorities, or providing clinical care to patients in trust hospitals or in primary care.Postal survey.Three health settings: 46 health authorities, 162 acute and/or community trust hospitals, and 96 primary care groups in England.566 subjects (46 directors of public health, 49 directors of purchasing, 375 clinical directors/consultants in hospitals, and 96 lead general practitioners).Knowledge of selected evidence-based guidance, previous use ever, beliefs in quality, usefulness, and perceived influence on practice.A usable response rate of 73% (407/560) was achieved; 82% (334/407) of respondents had consulted at least one source of evidence-based guidance ever in the past. Professionals in the health authorities were much more likely to be aware of the evidence-based guidance and had consulted more sources (mean number of different guidelines consulted 4.3) than either the hospital consultants (mean 1.9) or GPs in primary care (mean 1.8). There was little variation in the belief that the evidence-based guidance was of "good quality", but respondents from the health authorities (87%) were significantly more likely than either hospital consultants (52%) or GPs (57%) to perceive that any of the specified evidence-based guidance had influenced a change of practice. Across all settings, the least used route to accessing evidence-based guidance was the Internet. For several sources an effect was observed between use ever, the health region where the health professional worked, and the region where the guidance was produced or published. This was evident for some national sources as well as in those initiatives produced locally with predominantly local distribution networks.The evidence-based guidance specified was significantly more likely to be seen to have contributed to the decisions of public health specialists and commissioners than those of consultants in hospitals or of GPs in a primary care setting. Appropriate information support and dissemination systems that increase awareness, access, and use of evidence-based guidance at the clinical interface should be developed.

International audience; The main goal of this study was to determine the reproducibility of the reading of wrist trauma case radiographs using three different media: laser film, a picture archiving and communication systems (PACS) workstation, and paper with an optimized layout. The study was conducted retrospectively in 200 consecutive patients consulting at the emergency department for wrist trauma and who underwent wrist X-ray investigation using a computed radiography system. There were 82 men and 118 women. The mean age was 48.3 years (16–95 years). Our institutional review board does not require patient approval or informed consent for retrospective review of case records. The readings were made by two independent readers who analyzed the 200 patient radiographs consecutively in one session for each type of media: paper, laser film, and on a PACS dual-screen workstation. The inter-reader agreements were substantial or almost perfect, with kappa values of 0.83 (0.76–0.90) for the PACS, 0.83 (0.76–0.90) for film, and 0.80 (0.72–0.87) for paper. The inter-technique agreement was almost perfect in all cases. There is a high interobserver agreement between PACS, laser film, and paper readings for wrist trauma cases. With a layout of one radiograph on each sheet, paper could replace laser films to communicate the results of wrist radiographs in trauma cases for outpatients.

N Barber, professor of the practice of pharmacy M Schachter, senior lecturer and honorary consultant physician Objective—To develop a practitioner led definition of a prescribing error for use in quantitative studies of their incidence. Design—Two stage Delphi technique. Subjects—A panel of 34 UK judges, which included physicians, surgeons, pharmacists, nurses and risk managers. Main outcome measures—The extent to which judges agreed with a general definition of a prescribing error, and the extent to which they agreed that each of 42 scenarios represented a prescribing error. Results—Responses were obtained from 30 (88%) of 34 judges in the first Delphi round, and from 26 (87%) of 30 in the second round. The general definition of a prescribing error was accepted. The panel reached consensus that 24 of the 42 scenarios should be included as prescribing errors and that five should be excluded. In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not. Conclusions—Health care professionals are in broad agreement about the types of events that should be included and excluded as prescribing errors. A general definition of a prescribing error has been developed, together with more detailed guidance regarding the types of events that should be included. This definition allows the comparison of prescribing error rates among different prescribing systems and different hospitals, and is suitable for use in both research and clinical governance initiatives. (Quality in Health Care 2000;9:232–237) Key Words: prescribing errors; medication errors; definition of error

Background Decisions concerning drug safety and efficacy are generally based on pivotal evidence provided by clinical trials. Unfortunately, finding the relevant clinical trials is difficult and their results are only available in text-based reports. Systematic reviews aim to provide a comprehensive overview of the evidence in a specific area, but may not provide the data required for decision making. Methods We review and analyze the existing information systems and standards for aggregate level clinical trials information from the perspective of systematic review and evidence-based decision making. Results The technology currently used has major shortcomings, which cause deficiencies in the transfer, traceability and availability of clinical trials information. Specifically, data available to decision makers is insufficiently structured, and consequently the decisions cannot be properly traced back to the underlying evidence. Regulatory submission, trial publication, trial registration, and systematic review produce unstructured datasets that are insufficient for supporting evidence-based decision making. Conclusions The current situation is a hindrance to policy decision makers as it prevents fully transparent decision making and the development of more advanced decision support systems. Addressing the identified deficiencies would enable more efficient, informed, and transparent evidence-based medical decision making.

The clinical utility of genetic tests is determined by the outcomes following test use. Like other measures of value, it is often contested. Stakeholders may have different views about benefits and risks and about the importance of social versus health outcomes. They also commonly disagree about the evidence needed to determine whether a test is effective in achieving a specific outcome. Questions may be presented as factual disagreements, when they are actually debates about what information matters or how facts should be interpreted and used in clinical decision-making. Defining the different issues at stake is therefore an important element of policy-making. Key issues include evidence standards for test use, and in particular, the circumstances under which prospective controlled data should be required, as well as evidence on feasibility, cost and equitable delivery of testing; the goals of population-based screening programs, and in particular, the role of social outcomes in evaluating test value; and the appropriate uses and funding of tests that inform non-medical actions. Addressing each of these issues requires attention to stakeholder values and methods for effective deliberation that incorporate consumer as well as health professional perspectives.

Although there have been quite a number of theoretical and practical studies where axiomatic design (AD) principles have been used in the last few years, there is a lack of a comprehensive literature survey which evaluates and classifies these papers. This study provides a recognizable overview of literature on AD principles from the past 20 years and introduces a novel classification scheme covering 63 papers. Each article was classified into four main groups, namely the type of the axiom, the application area, the method, and the evaluation type. Findings of our paper indicate that most of the studies in the literature are application-based papers which use typically the independence axiom. While product design is put forward in the application area, the crisp approach is widely used as an evaluation type. A rise in the fuzzy evaluation based research studies using the information axiom for multi-attribute decision making problems has also been noticed. (C) 2010 Elsevier Ltd. All rights reserved.

There is increasing interest in the endoscopic treatment of Barrett’s esophagus. Endoscopic treatment has been utilized for many years, but in the past, no specific method has emerged as an appealing treatment option with appropriate safety, efficacy and ease of treatment for both patients and physicians. Recently there has been a growing literature related to the endoscopic ablation of Barrett’s esophagus using radiofrequency ablation (RFA) (Halo® system). In order to discuss when RFA is indicated for Barrett’s, one needs to know: (1) What is the ‘histology’ of the Barrett’s? Does the patient have intestinal metaplasia, low-grade dysplasia, high-grade dysplasia or intramucosal carcinoma? (2) What are the endoscopic options to be considered as opposed to RFA? What are the advantages and disadvantages of each? (3) What additional variables need to be examined?

Background Requests for troponin T, a biomarker for myocardial infarction, may be sent in a variety of clinical situations. In most cases, a single sample 12 hours or more after symptom onset should be sufficient for diagnosis. We chose to investigate how troponin T testing is used in our hospital with emphasis on those who had serial rather than single troponin measurements during their hospital stay. Methods Prospective survey of 50 patients with serial troponin T requests out of a total of 321 patients who had troponin T levels measured during the same time period. Results The time of symptom onset could be clearly identified in 40/50 patients. In 22 of these the first troponin was taken prior to 12 hours after symptom onset. For the 18 patients whose first troponin was taken after 12 hours, the second result remained in the same category (normal or high) as the first in all cases. This was not the case for 3/10 patients whose first troponin was sent within 12 hours and was normal. Early troponin results rarely affected immediate patient management and did not inform decisions about fibrinolytic therapy. Conclusions Serial troponin testing was most commonly due to a sample being sent within 12 hours of symptom onset or to unnecessary repetition of an appropriately timed sample. Patient management was rarely enhanced by early troponin testing.

PURPOSE In 2004, a commentary by Merenstein was published in JAMA describing how he was sued for engaging a patient in shared decision making for prostate cancer screening. The article sparked considerable debate on the impact of litigation on medical care. A natural experiment (a study assessing shared decision making under way at the practice that was sued) enabled us to evaluate whether physicians changed their prostate cancer screening behavior after the lawsuit. METHODS As part of a randomized controlled trial conducted between January 2002 and November 2004, patients and physicians completed exit questionnaires about prostate cancer screening discussions after health maintenance examinations. We compared responses before, during, and after physicians became aware of the lawsuit. RESULTS A total of 432 of 497 patients completed questionnaires (180 before the practice became aware of the lawsuit, 87 as knowledge of the case diffused through the practice, and 165 after publication of Merenstein’s commentary). Comparing patients’ responses over the 3 time periods, there were no changes in the average locus of decision-making control, time spent discussing screening, number of screening topics discussed, knowledge scores, or decisional conflict. The frequency with which physicians reported performing prostate-specific antigen testing increased (before vs after: 84% vs 90%; P = .03), and physicians were more likely to report that they, rather than the patients, had made the screening decision (before vs after: 3.3% vs 11.1%; P = .003). CONCLUSIONS The physicians in closest proximity to this well-known legal case continued to engage patients in shared decision making and to let patients decide whether to be screened. Prostate-specific antigen testing increased during this period.

Objectives: Our social cognition model posits that social knowledge and executive resources guide interpersonal decision making. We investigated this model by examining the resolution of standardised social dilemmas in patients with a social and executive disorder (SOC/EXEC) caused by frontotemporal dementia (FTD). Methods: Patients with SOC/EXEC (n = 12) and those with progressive aphasia (APH, n = 14) completed measures requiring resolution of social dilemmas (Guilford’s Cartoon Predictions Test), social cognition (theory of mind false belief vignettes and a behavioural rating measure of empathy) and executive measures of cognitive flexibility (Visual Verbal Test). Regression analysis related judgments of social dilemmas to cortical volume using voxel based morphometry of high resolution structural MRI. Results: Patients with SOC/EXEC were impaired in judgments of social dilemmas as well as theory of mind, self-awareness of empathy and cognitive flexibility. Patients with APH were much less impaired in the social and cognitive measures. There were strong correlations among social dilemma, theory of mind and mental flexibility measures in patients with SOC/EXEC, and stepwise regression showed that mental flexibility was most predictive of social dilemma judgments. Social dilemma impairments in the SOC/EXEC sample correlated with cortical atrophy in the orbital frontal, superior temporal, visual association and posterior cingulate regions of the right hemisphere. Conclusions: Deficits in patients with SOC/EXEC in resolving social dilemmas are related to depleted executive resources and social knowledge that appear to arise from disease that interrupts a right frontal–temporal neural network crucial for mediating social cognition.

The studies reported here examined differences in user behaviour when presented with a low-fidelity paper prototype compared to fully operational product, and evaluated the effectiveness of different types of enhanced labelling of controls. In the first study with a paper prototype, 30 users of high-pressure washers were asked to choose the settings of the temperature control for different cleaning objects, comparing standard with information-enriched control labelling. In the second study, 34 users operated a real high-pressure washer with different forms of control labelling. The results of both studies provided evidence for some benefits of an information-enriched control labelling over traditional temperature-centred controls labelling. Furthermore, a comparative analysis of the data of the two studies suggested that low-fidelity paper prototypes may have to be used with caution. Therefore, designers need to be aware that the behavioural effects induced by different design modifications may be overestimated when using paper prototypes. The implications of the findings are discussed within the framework of an enlarged concept of fidelity.

This paper discusses the relationship between environmental and economic performance and the influence of corporate strategies with regard to sustainability and the environment. After formulating a theoretical model, results are reported from an empirical analysis of the European paper manufacturing industry. New data are used to test hypotheses derived from the theoretical model, using environmental performance indices representing different corporate environmental strategy orientations. In particular, an emissions-based index largely reflecting end-of-pipe strategies and an inputs-based index reflecting integrated pollution prevention are distinguished. For the emissions-based index, a predominantly negative relationship between environmental and economic performance is found, whereas for the inputs-based index no significant link is found. This is consistent with the theoretical model, which predicts the possibility of different relationships. The results also show that for firms with pollution prevention-oriented corporate environmental strategies, the relationship between environmental and economic performance is more positive, thus making improvements in corporate sustainability more likely. Based on this last insight, managerial implications of this are discussed with regard to strategy choices, investment decisions and operations management.

Objectives: The purpose of this study was to describe the process used to decide which patients are admitted to the intensive care unit (ICU) at a hospital with special focus on access for neurosurgery patients, and evaluate it using “accountability for reasonableness”. Methods: Qualitative case study methodology was used. Data were collected from documents, interviews with key informants, and observations. The data were subjected to thematic analysis and evaluated using the four conditions of “accountability for reasonableness” (relevance, publicity, appeals, enforcement) to identify good practices and opportunities for improvement. Results: ICU admissions were based on the referring physician’s assessment of the medical need of the patient for an ICU bed. Non-medical criteria (for example, family wishes) also influenced admission decisions. Although there was an ICU bed allocation policy, patient need always superceded the bed allocation policy. ICU admission guidelines were not used. Admission decisions and reasons were disseminated to the ICU charge nurse, the bed coordinator, the ICU resident, the intensivist, and the requesting physician/surgeon by word of mouth and by written documentation in the patient’s chart, but not to the patient or family. Appeals occurred informally, through negotiations between clinicians. Enforcement of relevance, publicity, and appeals was felt to be either non-existent or deficient. Conclusions: Conducting a case study of priority setting decisions for patients requiring ICU beds, with a special focus on neurosurgical patients, and applying the ethical framework “accountability for reasonableness” can help critical care units improve the fairness of their priority setting.

To develop and evaluate an information service in which a "clinical informaticist" (a GP with training in evidence-based medicine) provided evidence-based answers to questions posed by GPs and nurse practitioners.Descriptive pilot study with systematic recording of the process involved in searching for and critically appraising literature. Evaluation by questionnaire and semi-structured interview.General practice.34 clinicians from two London primary care groups (Fulham and Hammersmith).Number and origin of questions; process and time involved in producing summaries; satisfaction with the service.All 100 clinicians in two primary care groups were approached. Thirty four agreed to participate, of whom 22 asked 60 questions over 10 months. Participants were highly satisfied with the summaries they received. For one third of questions the clinicians stated they would change practice in the index patient, and for 55% the participants stated they would change practice in other patients. Answering questions thoroughly was time consuming (median 130 minutes). The median turnaround time was 9 days; 82% of questions were answered within the timeframe specified by the questioner. Without the informaticist, one third of questions would not have been pursued.The clinical informaticist service increased access to evidence for busy clinicians. Satisfaction was high among users and clinicians stated that changes in practice would occur. However, uptake of the service was lower than expected (22% of those offered the service). Further research is needed into how this method of increasing access to evidence compares with other strategies, and whether it results in improved health outcomes for patients.

Three hundred and ninety one male employees aged 35-65 in a Swedish pulp and paper company were followed up for 22 years; 151 deaths were recorded by 31 December 1983. On the basis of data from 1961, indices for job decision latitude, job support, and other work related psychosocial factors were constructed as were five indices for non-work related social network factors. All indices were checked by life table analysis in respect of mortality. Job decision latitude and a combined index for job decision latitude and job support showed significant associations with mortality. These two indices were investigated by multivariate analysis with scale for evaluation of neuroticism and known somatic risk factors such as smoking, cholesterol, and systolic and diastolic blood pressure. Age, educational level, occupational status, physically heavy work, and general health state were also included in the multivariate analysis. Age, systolic blood pressure, the combined index for job decision latitude and job support, smoking, and neuroticism were shown to be independent predictors of mortality.