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1.  How do physicians decide to treat: an empirical evaluation of the threshold model 
Background
According to the threshold model, when faced with a decision under diagnostic uncertainty, physicians should administer treatment if the probability of disease is above a specified threshold and withhold treatment otherwise. The objectives of the present study are to a) evaluate if physicians act according to a threshold model, b) examine which of the existing threshold models [expected utility theory model (EUT), regret-based threshold model, or dual-processing theory] explains the physicians’ decision-making best.
Methods
A survey employing realistic clinical treatment vignettes for patients with pulmonary embolism and acute myeloid leukemia was administered to forty-one practicing physicians across different medical specialties. Participants were randomly assigned to the order of presentation of the case vignettes and re-randomized to the order of “high” versus “low” threshold case. The main outcome measure was the proportion of physicians who would or would not prescribe treatment in relation to perceived changes in threshold probability.
Results
Fewer physicians choose to treat as the benefit/harms ratio decreased (i.e. the threshold increased) and more physicians administered treatment as the benefit/harms ratio increased (and the threshold decreased). When compared to the actual treatment recommendations, we found that the regret model was marginally superior to the EUT model [Odds ratio (OR) = 1.49; 95% confidence interval (CI) 1.00 to 2.23; p = 0.056]. The dual-processing model was statistically significantly superior to both EUT model [OR = 1.75, 95% CI 1.67 to 4.08; p < 0.001] and regret model [OR = 2.61, 95% CI 1.11 to 2.77; p = 0.018].
Conclusions
We provide the first empirical evidence that physicians’ decision-making can be explained by the threshold model. Of the threshold models tested, the dual-processing theory of decision-making provides the best explanation for the observed empirical results.
doi:10.1186/1472-6947-14-47
PMCID: PMC4055375  PMID: 24903517
Medical decision-making; Threshold model; Dual-processing theory; Regret, Expected utility theory
2.  Racial/ethnic Differences in Body Mass Index: The Roles of Beliefs about Thinness and Dietary Restriction 
Body image  2008;5(3):291-298.
The greater BMI of African American relative to Caucasian women is implicated in racial/ethnic disparities in health outcomes. The principal aim of the current study was to evaluate a theoretical account of racial/ethnic differences in BMI. Thin-ideal internalization, the perceived romantic appeal of thinness, dietary restriction, weight, and height were assessed via self-report measures on a sample of female undergraduates of African American (n = 140) and Caucasian (n = 676) race/ethnicity. Using structural equation modeling, support was obtained for the primary hypothesis that racial/ethnic differences in BMI are explained by Caucasian women’s greater thin-ideal internalization and perceived romantic appeal of thinness, thereby resulting in greater levels of dietary restriction. Current findings illustrate the potential for racial/ethnic differences in sociocultural standards of appearance to influence racial/ethnic disparities in physical health, of which BMI is a marker, via effects on weight control behavior.
doi:10.1016/j.bodyim.2008.02.004
PMCID: PMC4029410  PMID: 18585109
Racial/ethnic differences; thin-ideal internalization; body mass; dietary restriction
3.  Breastfeeding Status and Maternal Cardiovascular Variables Across the Postpartum 
Journal of Women's Health  2013;22(5):453-459.
Abstract
Background
There have been recent reports that lactational history is associated with long-term women's health benefits. Most of these studies are epidemiological. If particular cardiometabolic changes that occur during lactation ultimately influence women's health later is unknown.
Methods
Seventy-one healthy women participated in a prospective postpartum study that provided an opportunity to study anthropometric, endocrine, immune, and behavioral variables across time. Variables studied were heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), C-reactive protein, body mass index (BMI), perceived stress, and hormones. A cohort of women without a change in breastfeeding (N=22) or formula feeding (N=23) group membership for 5 months was used for analysis of effects of feeding status. The data were analyzed using factorial repeated measures analysis of variance and analysis of covariance.
Results
SBP and HR declined across the postpartum and were significantly lower in breastfeeding compared to formula feeding mothers (p<0.05). These differences remained statistically significant when BMI was added to the model. Other covariates of income, stress, marital status, and ethnicity were not significantly associated with these variables over time. DBP was also lower, but the significance was reduced by the addition of BMI as a covariate. Stress also was lower in breastfeeders, but this effect was reduced by the addition of income as a covariate.
Conclusions
These data suggest that there are important physiological differences in women during months of breastfeeding. These may have roles in influencing or programming later risks for a number of midlife diseases.
doi:10.1089/jwh.2012.3981
PMCID: PMC3653385  PMID: 23659484
4.  Physiological and Exercise Capacity Improvements in Women Completing Cardiac Rehabilitation 
PURPOSE
We sought to examine the improvements in physiological outcomes, including exercise capacity, in women completing a 12-week gender-specific (tailored) compared to a traditional cardiac rehabilitation (CR) program.
METHODS
A 2-group randomized clinical trial compared symptom limited graded exercise test (SL-GXT), lipid, and anthropometric parameters among 99 women completing a traditional 12-week CR program to 137 women completing a tailored CR program.
RESULTS
Compared to baseline, improvement in estimated peak metabolic equivalents (METs) was similar (P=.159) between the tailored (6.0±2.7 to 7.6±2.8) and the traditional CR program (5.6±2.3 to 7.1±2.8). The amount of change in SL-GXT, anthropometric parameters, lipid profiles, and peak treadmill time from baseline to post-CR were also similar between the 2 groups. Given comparable improvements of the 2 CR programs, in the full cohort, factors independently associated with post-CR METs, in rank order, included baseline METs (part correlation=0.44, P<.001), perceived physical functioning (0.24, P<.001), waist circumference (−0.10, P=.006), and age (−0.11, P=.004). Factors independently associated with post-CR treadmill time included baseline treadmill time (part correlation=0.42, P<.001), perceived physical functioning (0.30, p<.001), waist circumference (−0.12, P=.002), and age (−0.10, P=.006).
CONCLUSIONS
Exercise capacity was significantly improved among women completing both CR programs. In the context of CR, modifiable factors positively associated with post-CR exercise capacity included reduced waist circumference and improved physical functioning. Future research on strategies for reducing abdominal obesity and improving perceived physical functioning and exercise capacity among women attending CR is warranted.
doi:10.1097/HCR.0b013e3182763192
PMCID: PMC3543779  PMID: 23221809
cardiac rehabilitation; women; exercise capacity; physical functioning
5.  Dual processing model of medical decision-making 
Background
Dual processing theory of human cognition postulates that reasoning and decision-making can be described as a function of both an intuitive, experiential, affective system (system I) and/or an analytical, deliberative (system II) processing system. To date no formal descriptive model of medical decision-making based on dual processing theory has been developed. Here we postulate such a model and apply it to a common clinical situation: whether treatment should be administered to the patient who may or may not have a disease.
Methods
We developed a mathematical model in which we linked a recently proposed descriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understand decision-making at the bedside and explain the widespread variation in treatments observed in clinical practice.
Results
We show that physician’s beliefs about whether to treat at higher (lower) probability levels compared to the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of benefit and harms as evaluated by both system I and II. Under some conditions, the system I decision maker’s threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the overtreatment often seen in the contemporary practice. The opposite can also occur as in the situations where empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system II using expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment that is also documented in the current medical practice.
Conclusions
We have developed the first dual processing model of medical decision-making that has potential to enrich the current medical decision-making field, which is still to the large extent dominated by expected utility theory. The model also provides a platform for reconciling two groups of competing dual processing theories (parallel competitive with default-interventionalist theories).
doi:10.1186/1472-6947-12-94
PMCID: PMC3471048  PMID: 22943520
6.  The Relationship Between Polymorphisms on Chromosome 9p21 and Age of Onset of Coronary Heart Disease in Black and White Women 
Aim: Genome-wide association studies have identified variants on chromosome 9p21 that are associated with coronary heart disease (CHD). The relationship between these variants and the age of onset of CHD is less clear. The aim of this study was to examine the allelic frequencies and haplotype structure of eight single-nucleotide polymorphisms (SNPs) on chromosome 9p21 in ethnically diverse women. We also explored the relationship between 9p21 SNPs and the age of CHD onset. Results: There was considerable interethnic allelic and haplotype diversity across the 9p21 locus with only two SNPs (rs10757274 and rs4977574) in perfect linkage disequilibrium in both races, and only a small proportion of the haplotypes shared between the racial groups. With the exception of rs1333040, whites with at least one copy of the 9p21 SNP risk alleles were found to have CHD from 1.45 (rs10116277) to 4.77 (rs2383206) years earlier than those with the wild-type alleles. Blacks carrying at least one copy of the risk allele (92%) for rs1333040 had a CHD age of onset that was 6.5 years earlier than those with the wild-type alleles. Conclusions: Different variants on chromosome 9p21 may influence CHD age of onset in whites and blacks.
doi:10.1089/gtmb.2010.0222
PMCID: PMC3101922  PMID: 21375403
7.  Prenatal depression and anxiety in Toxoplasma gondii positive women 
Objective
This study analyzed relationship between prenatal mood states and serological evidence of immune response to Toxoplasma gondii (T.gondii). A secondary aim was to determine if thyroid peroxidase (TPO) autoantibody status was related to T.gondii status.
Study Design
Pregnant women (N=414) were measured between 16 to 25 weeks gestation with demographic and mood questionnaires and a blood draw. All plasma samples were analyzed for TPO and T. gondii IgG, tryptophan, kynurenine and neopterin. Cytokines were available on a subset (N=142).
Results
Women with serological evidence of exposure to T. gondii (N=44) showed positive correlations between IgG levels, and the Profile of Mood Scales (POMS) depression and anxiety subscales. Plasma TNF-α was higher in T. gondii positive women.
Conclusions
Higher T. gondii IgG titers in infected women were related to anxiety and depression during pregnancy. Reactivation of T.gondii or immune responses to T.gondii may alter mood in pregnant women.
doi:10.1016/j.ajog.2011.01.004
PMCID: PMC3144318  PMID: 21345406
Toxoplasma gondii; depression; pregnancy
8.  The Effects of a Cardiac Rehabilitation Program Tailored for Women on Their Perceptions of Health: A Randomized Clinical Trial 
PURPOSE
The aim of this study was to compare the effects of a cardiac rehabilitation (CR) program tailored for women to a traditional program on perceptions of health among women with coronary heart disease.
METHODS
This 2-group randomized clinical trial compared the perceptions of health among 92 women completing a traditional 12-week CR program to 133 women completing a tailored program that included motivational interviewing guided by the Transtheoretical model of behavior change. Perceptions of health were measured using the SF-36 health survey at baseline, post-intervention, and at 6-month follow-up. ANOVA was used to compare changes in SF-36 subscale scores over time.
RESULTS
The group by time interaction was significant for the general health (F(2,446) = 3.80, P=.023), social functioning (F(2,446) = 4.85, P=.008), vitality (F(2,446) = 5.85, P=.003), and mental health (F(2,446) = 3.61, P=.028), subscales indicating that the pattern of change was different between the 2 groups. Of the 4 subscales on which there were significant group by time interactions, the tailored group demonstrated improved scores over time on all 4 while the traditional group improved on only the emotional role limitations and vitality subscales.
CONCLUSIONS
A tailored CR program improved general health perceptions, mental health, vitality, and social functioning in women when compared to traditional CR. To the extent that perceptions of health contribute to healthy behaviors fostered in CR programs, tailoring CR programs to alter perceptions of health may improve adherence.
doi:10.1097/HCR.0b013e3181f68acc
PMCID: PMC3018536  PMID: 21037482
9.  The Effects of a Cardiac Rehabilitation Program Tailored for Women on Global Quality of Life: A Randomized Clinical Trial 
Journal of Women's Health  2010;19(11):1977-1985.
Abstract
Background
Women with heart disease have adverse psychosocial profiles and poor attendance in cardiac rehabilitation (CR) programs. Few studies examine CR programs tailored for women for improving their quality of life (QOL).
Methods
This randomized clinical trial (RCT) compared QOL among women in a traditional CR program with that of women completing a tailored program that included motivational interviewing guided by the Transtheoretical Model (TTM) of behavior change. Two measures of QOL, the Multiple Discrepancies Theory questionnaire (MDT) and the Self-Anchoring Striving Scale (SASS), were administered to 225 women at baseline, postintervention, and 6-month follow-up. Analysis of Variance (ANOVA) was used to compare changes in QOL scores over time.
Results
Baseline MDT and SASS scores were 35.1 and 35.5 and 7.1 and 7.0 for the tailored and traditional CR groups, respectively. Postintervention, MDT and SASS scores increased to 37.9 and 7.9, respectively, for the tailored group compared with 35.9 and 7.1 for the traditional group. Follow-up scores were 37.7 and 7.6 for the tailored group and 35.7 and 7.1 for the traditional group. Significant group by time interactions were found. Subsequent tests revealed that MDT and SASS scores for the traditional group did not differ over time. The tailored group showed significantly increased MDT and SASS scores from baseline to posttest, and despite slight attenuation from posttest to 6-month follow-up, MDT and SASS scores remained higher than baseline.
Conclusions
The CR program tailored for women significantly improved global QOL compared with traditional CR. Future studies should explore the mechanisms by which such programs affect QOL.
doi:10.1089/jwh.2010.1937
PMCID: PMC2995341  PMID: 20846018
10.  Predicting Cardiac Rehabilitation Attendance In A Gender-tailored Randomized Clinical Trial 
doi:10.1097/HCR.0b013e3181d0c2ce
PMCID: PMC2913420  PMID: 20216324
Attendance; Exercise; Cardiac rehabilitation; Women
11.  The Influence of Cardiac Rehabilitation on Inflammation and Metabolic Syndrome in Women with Coronary Heart Disease 
Background
Metabolic syndrome (MetS) and elevated inflammatory markers, both predictors of future cardiovascular events, are more prevalent in women with coronary heart disease (CHD). The influence of cardiac rehabilitation (CR) on MetS and inflammatory biomarkers is not well characterized for women.
Purpose
The purpose of this paper is to examine the effects of a 12-week behaviorally enhanced CR exclusively for women compared to traditional CR on components of the MetS and inflammatory markers in women with CHD.
Methods
The randomized clinical trial employed 2 treatment groups; both receiving a comprehensive 12-week CR program, with 1 group receiving a motivationally enhanced intervention exclusively for women. A subset of 91 women (mean age 61.6 years) from the parent study provided serum samples to examine the effects of CR on high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and intercellular adhesion molecule-1 (ICAM-1).
Results
Following CR, the total sample of women demonstrated significant reductions in hsCRP (P=.002), IL-6 (P<.001), TNF-α (P=.010), and ICAM-1 (P=.016). Women in the gender-tailored CR program, significantly improved all biomarker levels compared to baseline (P<.05 for all) while those in the traditional group improved only hsCRP (P=<.05) and IL-6 (P<.05) levels. The combined study group demonstrated improvements in several components of the MetS (triglycerides, waist circumference, and systolic blood pressure) but not others (high-density lipoprotein cholesterol, fasting glucose, and diastolic blood pressure).
Conclusion
Cardiac rehabilitation promotes greater improvements in inflammatory biomarkers than in components of MetS for women with CHD. Improvements in body composition or weight may not be a precondition for the benefits of exercise due to loss of abdominal fat. Examining components of MetS as continuous variables is recommended to prevent lost information inherent in dichotomization.
doi:10.1097/JCN.0b013e3181b7e500
PMCID: PMC2913415  PMID: 19935427
metabolic syndrome; cardiac rehabilitation; inflammation; obesity; c-reactive protein (hsCRP); interleukin-6 (IL-6); intercellular adhesion molecule-1 (ICAM-1); tumor necrosis factor alpha (TNF-α)

Results 1-11 (11)