Making Decisions about Thromboprophylaxis in Pregnancy: Women's Values and Preferences

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 4833-4833
Author(s):  
Shannon M Bates ◽  
Pablo Alonso-Coello ◽  
Mark Eckman ◽  
Kari A Tikkinen ◽  
Shanil Ebrahim ◽  
...  
Keyword(s):  
Decision Making ◽  
High Risk ◽  
Risk Reduction ◽  
Real Life ◽  
Low Risk ◽  
Risk Of Recurrence ◽  
Hypothetical Scenario ◽  
The Future ◽  
History Of ◽  
Risk Scenario

Abstract Background: The risk of pregnancy-related venous thromboembolism (VTE) is increased in women with a history of thrombosis. Although antepartum low molecular weight heparin (LMWH) prophylaxis can reduce this risk; the baseline risk of recurrence and the absolute magnitude of the risk reduction with prophylaxis are uncertain. Further, LMWH prophylaxis is costly, burdensome, medicalizes pregnancy, and may increase the risk of bleeding. Therefore, uncertainty persists regarding the net benefit of thromboprophylaxis and recommendations about the use of antepartum LMWH should be sensitive to pregnant women’s values and preferences, which have not previously been studied. Methods: We undertook an international multicenter cross-sectional interview study that included women with a history of VTE who were pregnant, planning pregnancy, or might consider pregnancy in the future. Women were classified as high (5 to 10%) or low (1 to 5%) risk of recurrent antepartum VTE. We ascertained willingness to receive LMWH during pregnancy through direct choice exercises involving real-life scenarios using the participant’s estimated VTE (high or low) and bleeding risks, hypothetical scenarios (low, medium and high risk of recurrence) and a probability trade-off exercise. Study outcomes included the minimum absolute reduction in VTE risk at which women changed from declining to accepting LMWH, along with possible determinants of this threshold, and participant choice of management strategy in her real-life and the three hypothetical scenarios. Results: 123 women from seven centers in six countries participated. Using a fixed 16% VTE risk without prophylaxis, the mean threshold reduction in risk at which women were willing to use LMWH was 4.3% (95% CI, 3.5 – 5.1%). Pregnant women and those planning a pregnancy (compared to those who might consider pregnancy in the future) and those with less than 2 weeks of experience with using LMWH during pregnancy (compared to those with more experience) required a greater risk reduction to use prophylaxis. In the real life scenario, there was there a significant difference in the proportion of women choosing prophylaxis between those at high risk (87.1%) and low risk (60.0%) of recurrence (p=0.01). The proportion of women choosing to use LMWH prophylaxis was 65.1% for the low risk hypothetical scenario (4% risk of recurrence), 79.7% for the medium risk scenario (10% risk of recurrence) and 87.8% for the high risk scenario (16% risk of recurrence). Conclusions: Most women with prior VTE will choose prophylaxis during a subsequent pregnancy, regardless of whether they are categorized as high or low risk of recurrence. Nevertheless, 40% of lower risk women will decline LMWH, as will over 10% of high risk women. Thus, these results mandate individualized clinical decision-making for women considering LMWH use during pregnancy, and weak guideline recommendations for LMWH use that highlight the need for individualized decision-making. Disclosures No relevant conflicts of interest to declare.

‘Walking on ice’: The future of parole in a risk-obsessed society

2019 ◽  
pp. 136248061988055
Author(s):  
Monica Barry
Keyword(s):  
Risk Assessment ◽  
Decision Making ◽  
Criminal Justice ◽  
High Risk ◽  
Risk Reduction ◽  
The Public ◽  
The Future ◽  
Key Drivers ◽  
The Uk ◽  
Risk Assessment And Management

The aim of risk assessment and management in criminal justice is increasingly about minimizing opportunities to create harm to the public rather than maximizing opportunities to create change in offenders. This seems to be particularly the case in respect of parole, where the balance of public protection with rehabilitation has become increasingly unstable in prioritizing the former. This article examines parole decision making and management within the UK from the perspectives of both high risk offenders on licence and parole professionals. It discusses two key drivers to burgeoning recall rates: the stringency of licence conditions and the propensity of professionals to recall in the name of risk elimination rather than risk reduction. The article concludes that the effectiveness of parole is in question, not least in enabling re-entry and reintegration of high risk prisoners. In particular, the future sustainability of parole itself is deemed to be under threat.

Letter to the Editor

PEDIATRICS ◽  
1978 ◽  
Vol 61 (6) ◽  
pp. 940-940
Author(s):  
Peter Camfield ◽  
Carol Camfield
Keyword(s):  
High Risk ◽  
Natural History ◽  
Randomized Trial ◽  
Febrile Seizure ◽  
Febrile Seizures ◽  
Prospective Randomized Trial ◽  
Risk Of Recurrence ◽  
Letter To The Editor ◽  
History Of ◽  
Phenobarbital Administration

The riddle of febrile seizures is that despite their high risk of recurrence (35% to 50%), the natural history of the disorder is benign for the vast majority of children.1 If daily phenobarbital administration for several years is to be recommended after the first febrile seizure, it must be shown to be exceedingly effective and safe. The commendable study of Woff et al. is the second2 prospective randomized trial with concurrent controls of the efficacy of phenobarbital to prevent recurrent febrile seizures.

Playing different games

2021 ◽  
Author(s):  
Tamas Wells
Keyword(s):  
Decision Making ◽  
Political Decision ◽  
The Future ◽  
History Of ◽  
Political Decision Making

Drawing on this history of conceptual contests over democracy in Myanmar, this chapter looks forward to how contests over the meaning of democracy might shape areas of political decision-making and policy in Myanmar over the coming decade. How might the particular examples of narratives, and their political use – within activist networks, the NLD and aid agencies – apply to the future of Myanmar’s politics? What challenges might there be for activists, democratic leaders and aid agencies through future contests over the meaning of democracy?

Risk Preferences and Incentives for Evidence Acquisition and Disclosure

2020 ◽  
Vol 36 (2) ◽  
pp. 314-342
Author(s):  
Erin Giffin ◽  
Erik Lillethun
Keyword(s):  
Decision Making ◽  
High Risk ◽  
Optimal Design ◽  
Risk Aversion ◽  
Risk Preferences ◽  
Decision Rules ◽  
Low Risk ◽  
Risk Averse ◽  
Good Decision ◽  
Legal Rules

Abstract Civil disputes feature parties with biased incentives acquiring evidence with costly effort. Evidence may then be revealed at trial or concealed to persuade a judge or jury. Using a persuasion game, we examine how a litigant’s risk preferences influence evidence acquisition incentives. We find that high risk aversion depresses equilibrium evidence acquisition. We then study the problem of designing legal rules to balance good decision making against the costs of acquisition. We characterize the optimal design, which differs from equilibrium decision rules. Notably, for very risk-averse litigants, the design is “over-incentivized” with stronger rewards and punishments than in equilibrium. We find similar results for various common legal rules, including admissibility of evidence and maximum awards. These results have implications for how rules could differentiate between high risk aversion types (e.g., individuals) and low risk aversion types (e.g., corporations) to improve evidence acquisition efficiency.

Management strategies for women at high risk for breast and ovarian cancer: Are women satisfied?

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 1524-1524
Author(s):  
S. N. Westin ◽  
C. C. Sun ◽  
K. H. Lu ◽  
K. M. Schmeler ◽  
P. T. Soliman ◽  
...  
Keyword(s):  
Ovarian Cancer ◽  
Decision Making ◽  
Patient Satisfaction ◽  
High Risk ◽  
Risk Reduction ◽  
Patient Questionnaire ◽  
Breast And Ovarian Cancer ◽  
Brca Mutations ◽  
Reduction Strategy ◽  
Risk Reduction Strategy

1524 Background: Women at high risk for breast and ovarian cancer have two major management options to reduce their risk of ovarian cancer, periodic screening (PS) or prophylactic oophorectomy (PO). Little is known regarding patient satisfaction levels with choice of risk reduction strategy. Our objective was to determine levels of patient satisfaction with PO versus PS and to identify factors which may influence satisfaction. Methods: As part of a larger study, women who received BRCA1/2 testing before July 2005 were sent a follow-up patient questionnaire packet. We are reporting on the Cancer Worry Scale and Satisfaction With Decision (SWD) scale (range of possible scores, 6–30). The lowest 10th percentile of the SWD score (21) was used to define low satisfaction. Chi-square, t-Test and Mann-Whitney tests were used for statistical analyses. Results: A total of 540 surveys were mailed and 309 responses were received (57%). We excluded 127 patients due to history of an oophorectomy for benign or malignant indications or incomplete SWD scale. The median age of respondents was 48.2. 60/182 women (33%) had BRCA mutations and 64/182 (35.2%) underwent PO. The overall satisfaction rate among respondents was high (median score 29, range 14–30). Median SWD score was significantly higher in patients in the PO group compared to the PS group (30.0 vs. 26.5, p<.001). Patients with BRCA mutations had higher median SWD scores, regardless of management type (30.0 vs. 28.0, p=.013). Low satisfaction scores were associated with the perception that the decision between PO and PS was difficult to make (p=.001). Patients who expressed ongoing difficulty in their decision-making also had lower satisfaction scores (p=.016). Satisfaction was unrelated to demographics, clinical factors, or concerns of cancer risk. Conclusions: In our study, the majority of women at high risk for breast and ovarian cancer were satisfied with their choice of risk reduction strategy. In particular, women who chose PO had higher levels of overall satisfaction. Difficulty with decision-making was associated with lower satisfaction levels. Improved education and support of these women through the decision-making process may enhance overall levels of satisfaction with risk reduction strategy. No significant financial relationships to disclose.

scholarly journals The Allure of High-Risk Rewards in Huntington’s disease

2015 ◽  
Vol 22 (4) ◽  
pp. 426-435 ◽  
Author(s):  
Nelleke C. van Wouwe ◽  
Kristen E. Kanoff ◽  
Daniel O. Claassen ◽  
K. Richard Ridderinkhof ◽  
Peter Hedera ◽  
...  
Keyword(s):  
Decision Making ◽  
High Risk ◽  
Huntington's Disease ◽  
Huntington’S Disease ◽  
Neurodegenerative Disorder ◽  
Low Risk ◽  
Decision Bias ◽  
Clear Preference ◽  
High Reward ◽  
Risk Choice

AbstractObjectives: Huntington’s disease (HD) is a neurodegenerative disorder that produces a bias toward risky, reward-driven decisions in situations where the outcomes of decisions are uncertain and must be discovered. However, it is unclear whether HD patients show similar biases in decision-making when learning demands are minimized and prospective risks and outcomes are known explicitly. We investigated how risk decision-making strategies and adjustments are altered in HD patients when reward contingencies are explicit. Methods: HD (N=18) and healthy control (HC; N=17) participants completed a risk-taking task in which they made a series of independent choices between a low-risk/low reward and high-risk/high reward risk options. Results: Computational modeling showed that compared to HC, who showed a clear preference for low-risk compared to high-risk decisions, the HD group valued high-risks more than low-risk decisions, especially when high-risks were rewarded. The strategy analysis indicated that when high-risk options were rewarded, HC adopted a conservative risk strategy on the next trial by preferring the low-risk option (i.e., they counted their blessings and then played the surer bet). In contrast, following a rewarded high-risk choice, HD patients showed a clear preference for repeating the high-risk choice. Conclusions: These results indicate a pattern of high-risk/high-reward decision bias in HD that persists when outcomes and risks are certain. The allure of high-risk/high-reward decisions in situations of risk certainty and uncertainty expands our insight into the dynamic decision-making deficits that create considerable clinical burden in HD. (JINS, 2016, 22, 426–435)

scholarly journals Differences in neural and cognitive response to emotional faces in middle-aged dizygotic twins at familial risk of depression

2017 ◽  
Vol 47 (13) ◽  
pp. 2345-2357 ◽  
Author(s):  
K. W. Miskowiak ◽  
A. M. B. Svendsen ◽  
C. J. Harmer ◽  
R. Elliott ◽  
J. Macoveanu ◽  
...  
Keyword(s):  
High Risk ◽  
Face Processing ◽  
Familial Risk ◽  
Risk Groups ◽  
Low Risk ◽  
Middle Aged ◽  
Emotional Faces ◽  
Dizygotic Twins ◽  
History Of ◽  
History Of Depression

BackgroundNegative bias and aberrant neural processing of emotional faces are trait-marks of depression but findings in healthy high-risk groups are conflicting.MethodsHealthy middle-aged dizygotic twins (N = 42) underwent functional magnetic resonance imaging (fMRI): 22 twins had a co-twin history of depression (high-risk) and 20 were without co-twin history of depression (low-risk). During fMRI, participants viewed fearful and happy faces while performing a gender discrimination task. After the scan, they were given a faces dot-probe task, a facial expression recognition task and questionnaires assessing mood, personality traits and coping.ResultsUnexpectedly, high-risk twins showed reduced fear vigilance and lower recognition of fear and happiness relative to low-risk twins. During face processing in the scanner, high-risk twins displayed distinct negative functional coupling between the amygdala and ventral prefrontal cortex and pregenual anterior cingulate. This was accompanied by greater fear-specific fronto-temporal response and reduced fronto-occipital response to all emotional faces relative to baseline. The risk groups showed no differences in mood, subjective state or coping.ConclusionsLess susceptibility to fearful faces and negative cortico-limbic coupling during emotional face processing may reflect neurocognitive compensatory mechanisms in middle-aged dizygotic twins who remain healthy despite their familial risk of depression.

scholarly journals Skin and Mucosal Human Papillomavirus Seroprevalence in Persons with Fanconi Anemia

2015 ◽  
Vol 22 (4) ◽  
pp. 413-420 ◽  
Author(s):  
Rachel A. Katzenellenbogen ◽  
Joseph J. Carter ◽  
Joshua E. Stern ◽  
Melinda S. Butsch Kovacic ◽  
Parinda A. Mehta ◽  
...  
Keyword(s):  
Human Papillomavirus ◽  
High Risk ◽  
Fanconi Anemia ◽  
Hpv Vaccine ◽  
Hpv Vaccination ◽  
Low Risk ◽  
Luminex Assay ◽  
History Of ◽  
Hpv Types ◽  
And Behavior

ABSTRACTPersons with Fanconi anemia (FA) are at risk for human papillomavirus (HPV)-associated cancers; however, their natural HPV exposure and infection rates are unknown as is the adequacy with which they mount antibodies to HPV vaccination. This study aimed to determine, in 62 persons with FA, the seroprevalence of skin and mucosal HPV types, the seroprevalence in individuals self-reporting a history of HPV vaccination, and the factors associated with HPV seropositivity. A bead Luminex assay was used to determine seropositivity for HPV1, -2, and -4 (low-risk skin), -6 and -11 (low-risk mucosal, included in one HPV vaccine), -16 and -18 (high-risk mucosal, included in both HPV vaccines), and -52 and -58 (high-risk mucosal). Health- and behavior-related questionnaires were completed. Type-specific seroprevalence estimates and participant characteristics associated with seroprevalence were calculated; 48% reported HPV vaccination. Type-specific seropositivity in unvaccinated persons ranged from 7 to 21% for skin HPV types and 7 to 38% for mucosal HPV types. Among the unvaccinated participants, adults versus children demonstrated increased HPV1, -6, -16, and -58 seroprevalence of 45% versus 6%, 64% versus 22%, 64% versus 17%, and 36% versus 0%, respectively (allP< 0.05). The vaccinated participants versus the nonvaccinated participants demonstrated increased seroprevalence of HPV6, -11, -16, and -18 of 92% versus 38%, 92% versus 24%, 96% versus 34%, and 75% versus 7%, respectively (allP< 0.0001). Our data demonstrate that the unvaccinated participants had serologic evidence of prior skin and mucosal HPV infections and that seroprevalence increased among adults; in self-reported vaccinees, seroprevalence of HPV vaccine types was 75 to 96%.

scholarly journals Concordant Patterns of Brain Structure in Mothers with Recurrent Depression and Their Never-Depressed Daughters

2016 ◽  
Vol 38 (2) ◽  
pp. 115-123 ◽  
Author(s):  
Lara C. Foland-Ross ◽  
Negin Behzadian ◽  
Joelle LeMoult ◽  
Ian H. Gotlib
Keyword(s):  
High Risk ◽  
Gray Matter ◽  
Brain Structure ◽  
Low Risk ◽  
Maternal Risk ◽  
Increased Risk ◽  
Cortical Gray Matter ◽  
History Of ◽  
Depressed Mothers ◽  
Risk For Depression

Background: A growing body of research has demonstrated that having a mother with a history of major depressive disorder (MDD) is one of the strongest predictors of depression in adolescent offspring. Few studies, however, have assessed neural markers of this increased risk for depression, or examined whether risk-related anomalies in adolescents at maternal risk for depression are related to neural abnormalities in their depressed mothers. We addressed these questions by examining concordance in brain structure in two groups of participants: mothers with a history of depression and their never-depressed daughters, and never-depressed mothers and their never-depressed daughters. Method: We scanned mothers with (remitted; RMD) and without (control; CTL) a history of recurrent episodes of depression and their never-depressed daughters, computed cortical gray matter thickness, and tested whether mothers' thickness predicted daughters' thickness. Results: Both RMD mothers and their high-risk daughters exhibited focal areas of thinner cortical gray matter compared with their CTL/low-risk counterparts. Importantly, the extent of thickness anomalies in RMD mothers predicted analogous abnormalities in their daughters; this pattern was not present in CTL/low-risk dyads. Conclusions: We identified neuroanatomical risk factors that may underlie the intergenerational transmission of risk for MDD. Our findings suggest that there is concordance in brain structure in dyads that is affected by maternal depression, and that the location, direction, and extent of neural anomalies in high-risk offspring mirror those of their recurrent depressed mothers.

scholarly journals The Risk of Stroke Using CHA2 DS2 -VASc Score in Hemodialysis Patients at a Tertiary Hospital in Riyadh, Saudi Arabia

2019 ◽  
Vol 4 (7) ◽  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Stroke Risk ◽  
Hemodialysis Patients ◽  
Low Risk ◽  
High Risk Patients ◽  
Stroke Risk Factors ◽  
Increased Risk ◽  
Risk Patients ◽  
History Of

Introduction: Patients undergoing hemodialysis are at increased risk of stroke. However, less known about the impact of some of the stroke risk factors, and the value of stroke risk scores in determining the risk in those patients. Our main goal. To assess the risk factors for stroke in hemodialysis patients and the use of the new CHA2DS2-VASc score for stroke assessment. Methods: Single center, retrospective cohort study of 336 patients undergoing hemodialysis from June 24, 2018, to September 6, 2018, was recruited. Baseline demographics, clinical, and laboratory data were collected. We calculated the CHA2 DS2 -VASc score for stroke assessment in all patients and categorized them into high, moderate and low risk patients according to CHA2 DS2 - VASc score and subcategorized them to two groups atrial fibrillation (AFib) and Non- Atrial fibrillation (Non AFib) patients. Results: 336 patients were included in our study; the majority of patients were at high risk with a CHA2 DS2 -VASc Score mean of 2.9± 1.5, although history of stroke was observed only in 15 patients (4.46%). According to CHA2 DS2 - VASc score, 280 patients were at high risk, 172 (51.19%) were high-risk patients on treatment (anticoagulant or antiplatelet) and 108(32.14%) patients were high risk patients not on treatment 48 were at moderate risk (14.28%) and 8 were at low risk (2.38 %). Patients were divided into subgroups as non-AFib and AFib. In non-AFib patients 320 (95.23%), high-risk patients 103 (32.18%) were not treated; high-risk patients with treatment are 162 (50.62%), moderate patients were 47 (14.68%), 8(2.5%) was in low risk. AFib patients were 16 with a mean CHA2 DS2 -VASc score of 4.4±1.1. Patients with AFib were all at high risk except 1 was at moderate risk (6.25%). There were 11 (68.75%) patients on treatment and 5 (31.25%) patients not on treatment. The risk factors for stroke that were statistically significant in increasing score risk for all patients were: age > 65 (95% CI, -2.04– -1.29; p = 0.000), being female (95% CI, -1.36– -0.68; p = 0.000) hypertension (95% CI, -2.59– -1.37; p = 0.000), diabetes (95% CI, -2.10– -1.50; p = 0.000), CVD (95% CI, -2.07– -1.24; p=0.000), history of stroke or TIA (95% CI, -3.70– -2.03; p = 0.000), CHF or LVEF (95% CI, -2.28– - 0.91; p = 0.000). Conclusions: The risk of stroke in hemodialysis patients is significant according to the use of CHA2 DS2 -VASc score in Non-AFib hemodialysis patients shows supportive evidence of increased risk of stroke in those patients, which suggest the importance of close monitoring of patients with stroke risk factors by the nephrologist and the stroke team which will lead to the initiation of early prophylaxis in those patients.

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