Improving Weight of Evidence Approaches to Chemical Evaluations

Federal and other regulatory agencies often use or claim to use a weight of evidence (WoE) approach in chemical evaluation. Their approaches to the use of WoE, however, differ significantly, rely heavily on subjective professional judgment, and merit improvement. We review uses of WoE approaches in key articles in the peer‐reviewed scientific literature, and find significant variations. We find that a hypothesis‐based WoE approach, developed by Lorenz Rhomberg et al., can provide a stronger scientific basis for chemical assessment while improving transparency and preserving the appropriate scope of professional judgment. Their approach, while still evolving, relies on the explicit specification of the hypothesized basis for using the information at hand to infer the ability of an agent to cause human health impacts or, more broadly, affect other endpoints of concern. We describe and endorse such a hypothesis‐based WoE approach to chemical evaluation.     

Overcoming medication refusal using a patient-centered approach

The refusal of psychotropic medication is a challenge faced by many healthcare providers when treating patients with mental illness. Controversy surrounds medication refusal because some mental health professionals believe that psychiatric patients should be forced to take medications for the safety of the general public, while patients are often acutely aware of potential lifelong adverse side effects and are sometimes reluctant to comply. The proposed alternative to this problem begins with developing the patient-provider relationship through a patient-centered approach. This approach emphasizes the individual needs of patients and creates opportunities for input from patients about their care, which helps form relationships of mutual trust and respect between patients and providers. This article explores the literature to: (1) understand some of the challenges and controversies involved in patient medication refusal from a clinical and societal level; (2) identify some issues in a patient-centered approach; and (3) make some brief clinical and policy recommendations that might help to bring about an increase in the use of patient-centered care. Hopefully, as efforts are made toward a patient-centered approach, increased psychotropic medication adherence and decreased medication coercion will result as providers listen and act upon the needs of their patients.     

Curved versus straight scissors to avoid 3rd and 4th degree perineal tears: A randomised feasibility study

BackgroundSevere perineal tears sustained during childbirth cause significant distress and morbidity amongst women. The objective of this study was to compare the use of straight scissors for cutting an episiotomy with the use of curved scissors, which are designed to curve away from the anal sphincter.MethodsWe used a single-centre, randomised feasibility trial. The intervention was the use of curved scissors. Women were recruited during a prenatal visit and randomised in the delivery suite, when it became clear that an episiotomy was required. The feasibility outcomes were the proportion of women able to be recruited, randomised and followed up. We also calculated the incidence of obstetric anal sphincter injury when either straight or curved scissors were used to cut an episiotomy. Other outcomes assessed were pain, length of hospital stay, perineal infection and perineal dehiscence.ResultsOf the 155 patients recruited in the prenatal period, only 20 (12.9%) were eventually randomised at birth. The main reasons for the high loss were that women either did not have a vaginal delivery (38, 24.5%), or they did not need an episiotomy (72, 46.5%). Rates of obstetric anal sphincter injury and other outcomes were similar between groups.DiscussionAnal sphincter injury during childbirth remains an important problem. Although the use of curved scissors provides a theoretical solution, we found that the high attrition rate made feasibility of conducting a suitably powered, randomised trial using the current design untenable. Alternative strategies have been suggested to make any future study more viable.     

The Value of Information in Decision‐Analytic Modeling for Malaria Vector Control in East Africa

Decision analysis tools and mathematical modeling are increasingly emphasized in malaria control programs worldwide to improve resource allocation and address ongoing challenges with sustainability. However, such tools require substantial scientific evidence, which is costly to acquire. The value of information (VOI) has been proposed as a metric for gauging the value of reduced model uncertainty. We apply this concept to an evidenced‐based Malaria Decision Analysis Support Tool (MDAST) designed for application in East Africa. In developing MDAST, substantial gaps in the scientific evidence base were identified regarding insecticide resistance in malaria vector control and the effectiveness of alternative mosquito control approaches, including larviciding. We identify four entomological parameters in the model (two for insecticide resistance and two for larviciding) that involve high levels of uncertainty and to which outputs in MDAST are sensitive. We estimate and compare a VOI for combinations of these parameters in evaluating three policy alternatives relative to a status quo policy. We find having perfect information on the uncertain parameters could improve program net benefits by up to 5–21%, with the highest VOI associated with jointly eliminating uncertainty about reproductive speed of malaria‐transmitting mosquitoes and initial efficacy of larviciding at reducing the emergence of new adult mosquitoes. Future research on parameter uncertainty in decision analysis of malaria control policy should investigate the VOI with respect to other aspects of malaria transmission (such as antimalarial resistance), the costs of reducing uncertainty in these parameters, and the extent to which imperfect information about these parameters can improve payoffs.     

Restructuring of the Financial Industry: The Disappearance of Locally Owned Traditional Financial Services in Rural America

Restructuring in the financial services industry has altered the relationship between small business owners and capital. In the past small businesses have relied on relational, or soft data, lending from locally owned banks for capital. The proliferation of absentee‐owned local branch networks brought standardized practices, thus eliminating the autonomy of local loan officers to utilize soft data in loan decisions. In this article we examine the changes in the percentage of traditional financial services that are locally owned in three county types: metropolitan, micropolitan, and noncore. We utilize the Longitudinal Business Database at the U.S. Census Bureau Center for Economic Studies. We examine changes in local ownership of traditional financial services between 1976 and 2007. We find that the rate of decline of local ownership has been greatest in the noncore (most rural) counties. We also explore to what extent these patterns are related to the emergence of alternative financial services during the same period. We find that such alternative services are growing in all three county types, but at rates not significantly different than the population growth for these county types. We supplement our analysis with data from qualitative interviews with small business owners throughout rural Texas. We conclude with a discussion of implications and plans for future research.     

The Inability of Self-affirmations to Decrease Defensive Bias Toward an Alcohol-Related Risk Message Among High-Risk College Students

Abstract

Objective: To examine the efficacy of a self-affirmation task in deterring college alcohol misuse and the importance of preexisting beliefs in predicting subsequent behavior change. Participants: Heavy-drinking undergraduates (N = 110) participated during the 2011–2012 academic year. Methods: Participants were randomized to complete an affirmation or control task before reading an alcohol risk message. Alcohol-related beliefs and behaviors were assessed. Participants completed a 2-week online follow-up assessing alcohol-related behaviors. Results: Both groups reported increased perceived problem importance, but neither group displayed changes in personal risk. Follow-up assessment revealed similar, significant declines in peak consumption in both groups, with no significant between-group differences. Preexisting beliefs accounted for 5% to 10% of variance in drinking outcomes. Conclusions: An affirmation task does not seem to decrease defensive processing or alter high-risk drinking behaviors among college students and should not be utilized in lieu of more effective strategies.     

Supportive Housing for Addicted,Incarcerated Homeless Adults

ABSTRACT

Homeless populations often suffer from mental illness, substance abuse, and criminality. Interventions, such as supportive housing, can have positive impacts, although benefits can be limited. This study examined outcomes for clients (N = 102) of a new supportive housing intervention. Use of formal treatment, jail contact, and community stability were compared pre- and post-housing. Jail bookings and residential substance abuse treatment significantly declined post-housing, while clients improved in income level, access to food, and housing stability. Results from official justice and treatment system data suggest that supportive housing can lead to significant changes. Future research is necessary to understand the relationship between client characteristics and outcomes.