'Immunising' physicians against availability bias in diagnostic reasoning: A randomised controlled experiment

Background: Diagnostic errors have often been attributed to biases in physicians' reasoning. Interventions to 'immunise' physicians against bias have focused on improving reasoning processes and have largely failed. Objective: To investigate the effect of increasing physicians' relevant knowledge on their susceptibility to availability bias. Design, settings and participants: Three-phase multicentre randomised experiment with second-year internal medicine residents from eight teaching hospitals in Brazil. Interventions: Immunisation: Physicians diagnosed one of two sets of vignettes (either diseases associated with chronic diarrhoea or with jaundice) and compared/contrasted alternative diagnoses with feedback. Biasing phase (1 week later): Physicians were biased towards either inflammatory bowel disease or viral hepatitis. Diagnostic performance test: All physicians diagnosed three vignettes resembling inflammatory bowel disease, three resembling hepatitis (however, all with different diagnoses). Physicians who increased their knowledge of either chronic diarrhoea or jaundice 1 week earlier were expected to resist the bias attempt. Main outcome measurements: Diagnostic accuracy, measured by test score (range 0-1), computed for subjected-to-bias and not-subjected-to-bias vignettes diagnosed by immunised and not-immunised physicians. Results: Ninety-one residents participated in the experiment. Diagnostic accuracy differed on subjected-to-bias vignettes, with immunised physicians performing better than non-immunised physicians (0.40 vs 0.24; difference in accuracy 0.16 (95% CI 0.05 to 0.27); p=0.004), but not on not-subjected-to-bias vignettes (0.36 vs 0.41; difference -0.05 (95% CI -0.17 to 0.08); p=0.45). Bias only hampered non-immunised physicians, who performed worse on subjected-to-bias than not-subjected-to-bias vignettes (difference -0.17 (95% CI -0.28 to -0.05); p=0.005); immunised physicians' accuracy did not differ (p=0.56). Conclusions: An intervention directed at increasing knowledge of clinical findings that discriminate between similar-looking diseases decreased physicians' susceptibility to availability bias, reducing diagnostic errors, in a simulated setting. Future research needs to examine the degree to which the intervention benefits other disease clusters and performance in clinical practice. Trial registration number: 68745917.1.1001.0068

Numerical Application of a Stick-Slip Control and Experimental Analysis using a Test Rig

Part of the process of exploration and development of an oil field consists of the drilling operations for oil and gas wells. Particularly for deep water and ultra deep water wells, the operation requires the control of a very flexible structure which is subjected to complex boundary conditions such as the nonlinear interactions between drill bit and rock formation and between the drill string and borehole wall. Concerning this complexity, the stick-slip phenomenon is a major component related to the torsional vibration and it can excite both axial and lateral vibrations. With these intentions, this paper has the main goal of confronting the torsional vibration problem over a test rig numerical model using a real-time conventional controller. The system contains two discs in which dry friction torques are applied. Therefore, the dynamical behaviour were analysed with and without controlling strategies

Numerical Application of a Stick-Slip Control and Experimental Analysis using a Test Rig

Part of the process of exploration and development of an oil field consists of the drilling operations for oil and gas wells. Particularly for deep water and ultra deep water wells, the operation requires the control of a very flexible structure which is subjected to complex boundary conditions such as the nonlinear interactions between drill bit and rock formation and between the drill string and borehole wall. Concerning this complexity, the stick-slip phenomenon is a major component related to the torsional vibration and it can excite both axial and lateral vibrations. With these intentions, this paper has the main goal of confronting the torsional vibration problem over a test rig numerical model using a real-time conventional controller. The system contains two discs in which dry friction torques are applied. Therefore, the dynamical behaviour were analysed with and without controlling strategies

First experiences with adaptive co-management in Para, Brazilian Amazon

Adaptive Co-Management (ACM) is an integrative approach for implementing sustainable forest management. An ACM team started working on ACM in Para State in year 2000. Its pilot activities in Para were carried out in three sites, each representing different realities of communities established in the Eastern Amazon region. The research focused on the concept of Collaborative Diagnostic Studies (CDS) as an opportunity to replace extenally-driven background studies, which are important for documentation and impact monitoring, with a collaborative evaluation of an expert-defined set of criteria and indicators for assessing sustainability (C&I). The defined set of C&I was structured in three categories: collaboration, adaptive management of natural resources and impacts/conditions. A variety of participatory methods were tested, described and evaluated in relation to their contribution to ACM. Pilot studies showed that CDS are not suitable as a substitute for background studies. Special efforts have to be undertaken so as to diminish the danger of external dominance and to ensure the participation of local actors. The pilot studies also confirmed the need for a systematic and well structured documentation of the complex and dynamic processes related to ACM. Due to the promising results obtained so far, it is recommended to focus ACM research in Brazil on work shared with local researcher teams and existing community projects

Adaptive collaborative management: criteria and indicators for assessing sustainability

Adaptive Collaborative Management (ACM) is an integrative approach for implementing sustainable management of natural resources, based on a main hypothesis, that is: if there is a high degree of collaboration between stakeholders combined with a high adaptiveness of management systems, the result will be a higher degree of human well being and ecological sustainability. A worldwide network under the umbrella of the Center for International Forestry Research (CIFOR) is engaged in researching the potential and methodological aspects related to ACM. Communication is fundamental for facilitating the collaboration between the stakeholders. To support this communication and to enable a transparent and efficient discussion about sustainable forest management by rural communities, we developed an ACM set of criteria and indicators (C&I), which is presented here

Breakfast frequency, adiposity, and cardiovascular risk factors as markers in adolescents

To analyse the relationship between skipping breakfast and haemodynamic, metabolic, inflammatory, and cardiovascular risk factors in adolescents. A cross-sectional study was carried out with information from an ongoing cohort study in Presidente Prudente, São Paulo, Brazil. The sample comprised of 120 adolescents (11.7±0.8 years old) who met the following inclusion criteria: age between 11 and 14 years; enrolled in the school unit of elementary education; absence of any known disease; and no drug consumption. The parents or legal guardians of the patients signed a formal informed consent. Skipping breakfast was self-reported through face-to-face interviews. Blood pressure, intima-media thickness, trunk fatness, total and fractional cholesterol levels - high-density lipoprotein cholesterol and low-density lipoprotein cholesterol - triacylglycerol levels, and high-sensitivity C-reactive protein levels were measured. In this study, 47.5% (95% CI: 38.5-56.4%) of the adolescents reported skipping breakfast at least 1 day/week. Adolescents who skipped breakfast had higher values of trunk fatness and systolic blood pressure. Breakfast frequency was negatively related to systolic blood pressure (β -1.99 [-3.67; -0.31]) and z score dyslipidaemia (β -0.46 [-0.90; -0.01]), but this relationship was mediated by trunk fatness. Skipping breakfast is related to cardiovascular risk factors in adolescents, and this relationship was mainly mediated by trunk fatness.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq