Reducing bias in open-label trials where blinded outcome assessment is not feasible: strategies from two randomised trials

Background Blinded outcome assessment is recommended in open-label trials to reduce bias, however it is not always feasible. It is therefore important to find other means of reducing bias in these scenarios. Methods We describe two randomised trials where blinded outcome assessment was not possible, and discuss the strategies used to reduce the possibility of bias. Results TRIGGER was an open-label cluster randomised trial whose primary outcome was further bleeding. Because of the cluster randomisation, all researchers in a hospital were aware of treatment allocation and so could not perform a blinded assessment. A blinded adjudication committee was also not feasible as it was impossible to compile relevant information to send to the committee in a blinded manner. Therefore, the definition of further bleeding was modified to exclude subjective aspects (such as whether symptoms like vomiting blood were severe enough to indicate the outcome had been met), leaving only objective aspects (the presence versus absence of active bleeding in the upper gastrointestinal tract confirmed by an internal examination). TAPPS was an open-label trial whose primary outcome was whether the patient was referred for a pleural drainage procedure. Allowing a blinded assessor to decide whether to refer the patient for a procedure was not feasible as many clinicians may be reluctant to enrol patients into the trial if they cannot be involved in their care during follow-up. Assessment by an adjudication committee was not possible, as the outcome either occurred or did not. Therefore, the decision pathway for procedure referral was modified. If a chest x-ray indicated that more than a third of the pleural space filled with fluid, the patient could be referred for a procedure; otherwise, the unblinded clinician was required to reach a consensus on referral with a blinded assessor. This process allowed the unblinded clinician to be involved in the patient’s care, while reducing the potential for bias. Conclusions When blinded outcome assessment is not possible, it may be useful to modify the outcome definition or method of assessment to reduce the risk of bias

Essential versus accessory aspects of cell death: recommendations of the NCCD 2015

Cells exposed to extreme physicochemical or mechanical stimuli die in an uncontrollable manner, as a result of their immediate structural breakdown. Such an unavoidable variant of cellular demise is generally referred to as ‘accidental cell death’ (ACD). In most settings, however, cell death is initiated by a genetically encoded apparatus, correlating with the fact that its course can be altered by pharmacologic or genetic interventions. ‘Regulated cell death’ (RCD) can occur as part of physiologic programs or can be activated once adaptive responses to perturbations of the extracellular or intracellular microenvironment fail. The biochemical phenomena that accompany RCD may be harnessed to classify it into a few subtypes, which often (but not always) exhibit stereotyped morphologic features. Nonetheless, efficiently inhibiting the processes that are commonly thought to cause RCD, such as the activation of executioner caspases in the course of apoptosis, does not exert true cytoprotective effects in the mammalian system, but simply alters the kinetics of cellular demise as it shifts its morphologic and biochemical correlates. Conversely, bona fide cytoprotection can be achieved by inhibiting the transduction of lethal signals in the early phases of the process, when adaptive responses are still operational. Thus, the mechanisms that truly execute RCD may be less understood, less inhibitable and perhaps more homogeneous than previously thought. Here, the Nomenclature Committee on Cell Death formulates a set of recommendations to help scientists and researchers to discriminate between essential and accessory aspects of cell death

Is the left-right scale a valid measure of ideology? Individual-level variation in associations with "left" and "right" and left-right self-placement

In order to measure ideology, political scientists heavily rely on the so-called left-right scale. Left and right are, however, abstract political concepts and may trigger different associations among respondents. If these associations vary systematically with other variables this may induce bias in the empirical study of ideology. We illustrate this problem using a unique survey that asked respondents open-ended questions regarding the meanings they attribute to the concepts "left" and "right". We assess and categorize this textual data using topic modeling techniques. Our analysis shows that variation in respondents’ associations is systematically related to their self-placement on the left-right scale and also to variables such as education and respondents’ cultural background (East vs. West Germany). Our findings indicate that the interpersonal comparability of the left-right scale across individuals is impaired. More generally, our study suggests that we need more research on how respondents interpret various abstract concepts that we regularly use in survey questions

Concentration-Dependent, Size-Independent Toxicity of Citrate Capped AuNPs in Drosophila melanogaster

The expected potential benefits promised by nanotechnology in various fields have led to a rapid increase of the presence of engineered nanomaterials in a high number of commercial goods. This is generating increasing questions about possible risks for human health and environment, due to the lack of an in-depth assessment of the physical/chemical factors responsible for their toxic effects. In this work, we evaluated the toxicity of monodisperse citrate-capped gold nanoparticles (AuNPs) of different sizes (5, 15, 40, and 80 nm) in the model organism Drosophila melanogaster, upon ingestion. To properly evaluate and distinguish the possible dose- and/or size-dependent toxicity of the AuNPs, we performed a thorough assessment of their biological effects, using two different dose-metrics. In the first approach, we kept constant the total surface area of the differently sized AuNPs (Total Exposed Surface area approach, TES), while, in the second approach, we used the same number concentration of the four different sizes of AuNPs (Total Number of Nanoparticles approach, TNN). We observed a significant AuNPs-induced toxicity in vivo, namely a strong reduction of Drosophila lifespan and fertility performance, presence of DNA fragmentation, as well as a significant modification in the expression levels of genes involved in stress responses, DNA damage recognition and apoptosis pathway. Interestingly, we found that, within the investigated experimental conditions, the toxic effects in the exposed organisms were directly related to the concentration of the AuNPs administered, irrespective of their size

Breast cancer risk and drinking water contaminated by wastewater: a case control study

BACKGROUND: Drinking water contaminated by wastewater is a potential source of exposure to mammary carcinogens and endocrine disrupting compounds from commercial products and excreted natural and pharmaceutical hormones. These contaminants are hypothesized to increase breast cancer risk. Cape Cod, Massachusetts, has a history of wastewater contamination in many, but not all, of its public water supplies; and the region has a history of higher breast cancer incidence that is unexplained by the population's age, in-migration, mammography use, or established breast cancer risk factors. We conducted a case-control study to investigate whether exposure to drinking water contaminated by wastewater increases the risk of breast cancer. METHODS: Participants were 824 Cape Cod women diagnosed with breast cancer in 1988–1995 and 745 controls who lived in homes served by public drinking water supplies and never lived in a home served by a Cape Cod private well. We assessed each woman's exposure yearly since 1972 at each of her Cape Cod addresses, using nitrate nitrogen (nitrate-N) levels measured in public wells and pumping volumes for the wells. Nitrate-N is an established wastewater indicator in the region. As an alternative drinking water quality indicator, we calculated the fraction of recharge zones in residential, commercial, and pesticide land use areas. RESULTS: After controlling for established breast cancer risk factors, mammography, and length of residence on Cape Cod, results showed no consistent association between breast cancer and average annual nitrate-N (OR = 1.8; 95% CI 0.6 – 5.0 for ≥ 1.2 vs. < .3 mg/L), the sum of annual nitrate-N concentrations (OR = 0.9; 95% CI 0.6 – 1.5 for ≥ 10 vs. 1 to < 10 mg/L), or the number of years exposed to nitrate-N over 1 mg/L (OR = 0.9; 95% CI 0.5 – 1.5 for ≥ 8 vs. 0 years). Variation in exposure levels was limited, with 99% of women receiving some of their water from supplies with nitrate-N levels in excess of background. The total fraction of residential, commercial, and pesticide use land in recharge zones of public supply wells was associated with a small statistically unstable higher breast cancer incidence (OR = 1.4; 95% CI 0.8–2.4 for highest compared with lowest land use), but risk did not increase for increasing land use fractions. CONCLUSION: Results did not provide evidence of an association between breast cancer and drinking water contaminated by wastewater. The computer mapping methods used in this study to link routine measurements required by the Safe Drinking Water Act with interview data can enhance individual-level epidemiologic studies of multiple health outcomes, including diseases with substantial latency

Active Hydrothermal Features as Tourist Attractions

Tourists are looking increasingly for adventurous experiences by exploring unusual and interesting landscapes. Active volcanic and hydrothermal landscapes and their remarkable manifestations of geysers, fumaroles and boiling mud ponds are some of the surface features that fascinate visitors of National Parks, Geoparks and World Heritage areas worldwide. The uniqueness of hydrothermal activity based on volcanism has provided popular tourist attractions in many countries for several thousand years. The Romans for example have used hydrothermal springs on the Italian island Ischia and visited the Campi Flegrei for recreational purposes. In Iceland the original Geysir already attracted international visitors over 150 years ago, who came to observe this spectacular hydrothermal phenomenon. In Greece and Turkey volcanic hot springs have historically provided attractive destinations, as well as in New Zealand, Japan and the Americas. The fact that locations with hydrothermal activity based on active volcanism have acquired various forms of protected site status, adds a further dimension to their attraction and demonstrates a significant contribution to sustainable and nature based tourism. Countries such as Iceland, New Zealand and Japan have a long tradition of using hydrothermal activity in its various forms to offer tourists a unique natural experience. These environments however are also known for their unpredictable and potentially hostile nature, as the use of hydrothermal features as a natural resource for tourism does harbour certain risks with the potential to affect human health and safety. Hydrothermal systems have erupted in the past, thereby causing the destruction of their immediate environment. Depending on the level of magnitude explosions of super heated water and steam mixed with fractured rocks and hot mud can be violent enough to create craters varying in size from a few metres to several hundred metres in diameter. Apart from unexpected eruptions of hydrothermal vents with the potential to cause thermal burns, further risk factors include seismic activity such as earthquakes, lethal gas emissions of hydrogen sulphide (H2S) as well as ground instability through hydrothermal alteration. While it is essential to prevent injuries to tourists the management of hydrothermal hazards remains problematic. Precursory signs are not well understood by the general public and the communication of imminent danger is frequently unachievable. As a consequence serious thought needs to be given to the risk factors and the potential danger of areas in the proximity of active hydrothermal manifestations such as extreme hot springs and geysers. To improve the safety standards in hydrothermal landscapes that are used as main features in tourism, strategic guidelines for best practice management must cover ALL active volcanic and hydrothermal areas. This chapter looks at management issues at hydrothermal destinations with special consideration of areas where these unique features are integrated as tourist attractions. Examples from destinations traditionally based on active volcanic and hydrothermal phenomena are presented as case studies to highlight the risk management processes in individual countries. Potential hazards in volcanic and hydrothermal areas are assessed with a focus on the prevention of accidents and injuries to tourists

Evidence-based Kernels: Fundamental Units of Behavioral Influence

This paper describes evidence-based kernels, fundamental units of behavioral influence that appear to underlie effective prevention and treatment for children, adults, and families. A kernel is a behavior–influence procedure shown through experimental analysis to affect a specific behavior and that is indivisible in the sense that removing any of its components would render it inert. Existing evidence shows that a variety of kernels can influence behavior in context, and some evidence suggests that frequent use or sufficient use of some kernels may produce longer lasting behavioral shifts. The analysis of kernels could contribute to an empirically based theory of behavioral influence, augment existing prevention or treatment efforts, facilitate the dissemination of effective prevention and treatment practices, clarify the active ingredients in existing interventions, and contribute to efficiently developing interventions that are more effective. Kernels involve one or more of the following mechanisms of behavior influence: reinforcement, altering antecedents, changing verbal relational responding, or changing physiological states directly. The paper describes 52 of these kernels, and details practical, theoretical, and research implications, including calling for a national database of kernels that influence human behavior