BackgroundThe management of multiple sclerosis (MS) is rapidly changing by the introduction of new and more effective disease-modifying agents. The importance of risk stratification was confirmed by results on disease progression predicted by different risk score systems. Despite these advances, we know very little about medical decisions under uncertainty in the management of MS. The goal of this study is to i) identify whether overconfidence, tolerance to risk/uncertainty, herding influence medical decisions, and ii) to evaluate the frequency of therapeutic inertia (defined as lack of treatment initiation or intensification in patients not at goals of care) and its predisposing factors in the management of MS.Methods/DesignThis is a prospective study comprising a combination of case-vignettes and surveys and experiments from Neuroeconomics/behavioral economics to identify cognitive distortions associated with medical decisions and therapeutic inertia. Participants include MS fellows and MS experts from across Spain. Each participant will receive an individual link using Qualtrics platform© that includes 20 case-vignettes, 3 surveys, and 4 behavioral experiments. The total time for completing the study is approximately 30–35 min. Case vignettes were selected to be representative of common clinical encounters in MS practice. Surveys and experiments include standardized test to measure overconfidence, aversion to risk and ambiguity, herding (following colleague’s suggestions even when not supported by the evidence), physicians’ reactions to uncertainty, and questions from the Socio-Economic Panel Study (SOEP) related to risk preferences in different domains. By applying three different MS score criteria (modified Rio, EMA, Prosperini’s scheme) we take into account physicians’ differences in escalating therapy when evaluating medical decisions across case-vignettes.ConclusionsThe present study applies an innovative approach by combining tools to assess medical decisions with experiments from Neuroeconomics that applies to common scenarios in MS care. Our results will help advance the field by providing a better understanding on the influence of cognitive factors (e.g., overconfidence, aversion to risk and uncertainty, herding) on medical decisions and therapeutic inertia in the management of MS which could lead to better outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12883-016-0577-4) contains supplementary material, which is available to authorized users.

Background and Purpose— Atrial fibrillation (AF) increases the risk of stroke and is associated with poor stroke outcomes. Limited tools are available to evaluate clinical outcomes and response to thrombolysis in stroke patients with AF. Methods— We applied the iScore ( http://www.sorcan.ca/iscore ), a validated risk score, to consecutive patients with an acute ischemic stroke admitted to stroke centers in the Registry of the Canadian Stroke Network. The main outcome considered was a favorable outcome (defined as a modified Rankin scale 0–2) at discharge after thrombolysis. Secondary outcomes included intracerebral hemorrhage, death at 30 days, and at 1 year stratified by terciles of the iScore. Results— Among 12 686 patients with an acute ischemic stroke, 2185 (17.2%) had AF. Overall, AF patients had higher risk of death at 30 days (22.3% versus 10.2%; P <0.0001), 1 year (37.1% versus 19.5%; P <0.0001) and death or disability at discharge (69.7% versus 54.7%; P <0.0001) compared with non-AF patients. After adjustment, thrombolysis was associated with a favorable outcome for patients without AF (relative risk, 1.18; 95% CI, 1.10–1.27), but no benefit was observed for patients with AF (relative risk, 0.91; 95% CI, 0.71–1.17). There was a modestly increased risk of intracranial hemorrhage (any type) (16.5% versus 11.6%; relative risk, 1.42; 95% CI, 1.05–1.91) after thrombolysis among AF compared with non-AF patients. In the logistic regression analysis, there was an interaction between tPA and iScore for a favorable outcome ( P -value interaction <0.001). The interaction also was significant ( P <0.0012) among patients without AF, but did not reach significance ( P =0.17) in patients with AF. Conclusions— Stroke patients with AF have higher mortality, greater risk of intracerebral hemorrhage, and a similar response trend to thrombolysis compared with non-AF patients.