Decision-making under uncertainty: A Brehmerian approach

This article discusses the contributions of the late Professor Berndt Brehmer with an emphasis on dynamic decision making under uncertainty. This concept has a long history as ambiguity implied in selective attention, later emphasised by prospect theory, which incorporates a time dimension. Time may be a solution to problems of uncertainty, not least the timing of decisions with each other and with environmental developments. This approach sees  decision making, from a process perspective, ultimately asking whether it makes sense to frame decisions as specific events or as an expression of an ongoing design process where the possibility spaces are expanded rather than limited to decision making among pre-existing alternatives. A dynamic view of the time dimension also encourages decision making as learning through probing actions and negotiation and collaboration, as well as with the environment. As much as this may sound like a recipe for managing second-track processes, it is also a recipe for managing through direct interaction, albeit a less-than-objective one understood through the biased perception of boundedly rational actors

Preoperative sleep quality and adverse pain outcomes after total hip arthroplasty

Background: Sleep disturbance is thought to aggravate acute postoperative pain. The influence of preoperative sleep problems on pain control in the long-term and development of chronic postsurgical pain is largely unknown. Methods: This prospective, observational study aimed to examine the links between preoperative sleep disturbance (Pittsburgh Sleep Quality Index, PSQI) and pain severity (Brief Pain Inventory, BPI) 6 months postoperative (primary outcome), objective measures of pain and postoperative pain control variables (secondary outcomes). Patients (n = 52) with disabling osteoarthritis (OA) pain undergoing total hip arthroplasty (THA) were included. Quantitative sensory testing (QST) was performed preoperatively on the day of surgery to evaluate pain objectively. Clinical data, as well as measures of sleep quality and pain, were obtained preoperatively and longitudinally over a 6-month period. Results: Preoperatively, sleep disturbance (i.e., PSQI score >5) occurred in 73.1% (n = 38) of THA patients, and pain severity was high (BPI pain severity 5.4 ± 1.3). Regression models, adjusting for relevant covariates, showed that preoperative PSQI score predicted pain severity 6 months postoperative (β = 0.091 (95% CI 0.001–0.181), p =.048, R2 = 0.35). Poor sleep quality was associated with increased pressure pain sensitivity and impaired endogenous pain inhibitory capacity (R2 range 0.14–0.33, all p's < 0.04). Moreover, preoperative sleep disturbance predicted increased opioid treatment during the first 24 hr after surgery (unadjusted β = 0.009 (95% CI 0.002–0.015) mg/kg, p =.007, R2 = 0.15). Conclusions: Preoperative sleep disturbance is prevalent in THA patients, is associated with objective measures of pain severity, and independently predicts immediate postoperative opioid treatment and poorer long-term pain control in patients who have undergone THA. Significance: Poor sleep quality and impaired sleep continuity are associated with heightened pain sensitivity, but previous work has not evaluated whether preoperative sleep problems impact long-term postoperative pain outcomes. Here, we show that sleep difficulties prior to total hip arthroplasty adversely predict postoperative pain control 6 months after surgery. Given sleep difficulties robustly predict pain outcomes, targeting and improving sleep may have salutary effects on postoperative pain reports and management

Sex Differences, Sleep Disturbance and Risk of Persistent Pain Associated With Groin Hernia Surgery : A Nationwide Register-Based Cohort Study

Persistent pain after groin hernia repair is a major health problem. Sleep disturbance is associated with heightened pain sensitivity. The main objective of this study was to examine the role of sleep disturbance in the development and long-term maintenance of chronic postherniorrhaphy inguinal pain (CPIP), with exploration of sex differences. From 2012 to 2017, a national cohort of patients with prior groin hernia repair (n = 2084;45.8% females) were assessed for the development of CPIP 12 months after surgery. Patients then underwent long-term (median 5.0 years) follow-up to evaluate the contribution of sex and sleep disturbance on the maintenance of CPIP. Associations between pre- and postoperative sleep problems (assessed at long-term follow-up) and CPIP were tested using logistic regression. Females had higher rates of CPIP with negative impact on daily activities 12 months after surgery as compared to males (14.6 vs 9.2%, P <.0005), and were more likely to have moderate-severe CPIP in the long-term (3.1 vs 1.2%, P =.003). Preoperative sleep problems predicted development of CPIP 12 months after surgery (adjusted odds ratio [aOR] 1.76 [95%CI 1.26–2.46], P =.001) and CPIP in the long-term (aOR 2.20 [1.61–3.00], P <.0001). CPIP was associated with insomnia and depression. Sleep disturbance may increase the risk for CPIP, and contribute to maintenance of postsurgical pain. Perspective: Females are at heightened risk for CPIP as compared to males. Increased severity of pain symptoms are linked to poorer sleep and psychiatric morbidity. Given the robust associations between sleep disturbance and CPIP, interventions which consolidate and promote sleep, especially in females, may improve long-term pain control