Myopic loss aversion is the combination of a greater sensitivity to losses than to gains and a tendency to evaluate outcomes frequently. Two implicat

Context: The definition of what constitutes a normal TSH during pregnancy is in flux. Recent studies suggested that the first trimester upper limit of normal for TSH should be 2.5 mIU/liter. Objective: The objective of the study was to evaluate the pregnancy loss and preterm delivery rate in first-trimester thyroid peroxidase antibody-negative women with TSH values between 2.5 and 5.0 mIU/liter. Design: The present study is a component of a recently published large-scale prospective trial that evaluated the impact of levothyroxine treatment on maternal and neonatal complications in thyroid peroxidase-positive women with TSH levels above 2.5 mIU/liter. The present study evaluated 4123 thyroid peroxidase antibody-negative women with TSH levels at or below 5.0 mIU/liter. Women were divided into two groups based on their initial TSH: group A, TSH level below 2.5 mIU/liter, excluding hyperthyroid women defined as an undetectable TSH with an elevated free T₄, and group B, TSH level between 2.5 and 5.0 mIU/liter. Setting: The study was conducted at two ambulatory clinics of community hospitals in southern Italy. Patients: A total of 4123 women were evaluated. Intervention: There was no intervention. Main Outcome Measures: The incidence of pregnancy loss and preterm delivery in group A as compared with group B was measured. Results: The rate of pregnancy loss was significantly higher in group B as compared with group A (6.1 vs. 3.6% respectively, P = 0.006). There was no difference in the rate of preterm delivery between the two groups. Conclusions: The increased incidence of pregnancy loss in pregnant women with TSH levels between 2.5 and 5.0 mIU/liter provides strong physiological evidence to support redefining the TSH upper limit of normal in the first trimester to 2.5 mIU/liter.

Context: Thyroid disease during pregnancy has been associated with multiple adverse outcomes. Whether all women should be screened for thyroid disease during pregnancy is controversial. Objective: The objective of the study was to determine whether treatment of thyroid disease during pregnancy decreases the incidence of adverse outcomes and compare the ability of universal screening vs. case finding in detecting thyroid dysfunction. Design: Women in the first trimester were randomly assigned to the universal screening group or case-finding group. Women in both groups were stratified as high risk or low risk based on risk factors for thyroid disease. All women in the universal screening group, and high-risk women in the case-finding group, were immediately tested for free T₄, TSH, and thyroid peroxidase antibody. Low-risk women in the case-finding group had their sera tested postpartum. Setting: The study was conducted at two ambulatory clinics of community hospitals in southern Italy. Patients: A total of 4562 women were randomly assigned to the universal screening or case-finding group. Intervention: Intervention included levothyroxine in women with a TSH above 2.5 mIU/liter in TPO antibody-positive women and antithyroid medication in women with a undetectable TSH and elevated free T₄. Main Outcome Measure: Total number of adverse obstetrical and neonatal outcomes was measured. Results: No significant differences were seen in adverse outcomes between the case-finding and universal screening groups. Adverse outcomes were less likely to occur among low-risk women in the screening group than those in the case-finding group. Conclusions: Universal screening compared with case finding did not result in a decrease in adverse outcomes. Treatment of hypothyroidism or hyperthyroidism identified by screening a low-risk group was associated with a lower rate of adverse outcomes.

▪ Abstract For many decades, research in judgment and decision making has examined behavioral violations of rational choice theory. In that framework, rationality is expressed as a single correct decision shared by experimenters and subjects that satisfies internal coherence within a set of preferences and beliefs. Outside of psychology, social scientists are now debating the need to modify rational choice theory with behavioral assumptions. Within psychology, researchers are debating assumptions about errors for many different definitions of rationality. Alternative frameworks are being proposed. These frameworks view decisions as more reasonable and adaptive than previously thought. For example, “rule following.” Rule following, which occurs when a rule or norm is applied to a situation, often minimizes effort and provides satisfying solutions that are “good enough,” though not necessarily the best. When rules are ambiguous, people look for reasons to guide their decisions. They may also let their emotions take charge. This chapter presents recent research on judgment and decision making from traditional and alternative frameworks.

This article has been corrected. For original version, click “Original Version (PDF)” in column 2. A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care. To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes. An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked. 14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities. Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans. Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters. Only 4 case scenarios were used. The study assessed physicians' propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context. Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance. U.S. Department of Veterans Affairs Health Services Research and Development Service.