Centre selection for clinical trials and the generalisability of results: a mixed methods study.

BACKGROUND: The rationale for centre selection in randomised controlled trials (RCTs) is often unclear but may have important implications for the generalisability of trial results. The aims of this study were to evaluate the factors which currently influence centre selection in RCTs and consider how generalisability considerations inform current and optimal practice. METHODS AND FINDINGS: Mixed methods approach consisting of a systematic review and meta-summary of centre selection criteria reported in RCT protocols funded by the UK National Institute of Health Research (NIHR) initiated between January 2005-January 2012; and an online survey on the topic of current and optimal centre selection, distributed to professionals in the 48 UK Clinical Trials Units and 10 NIHR Research Design Services. The survey design was informed by the systematic review and by two focus groups conducted with trialists at the Birmingham Centre for Clinical Trials. 129 trial protocols were included in the systematic review, with a total target sample size in excess of 317,000 participants. The meta-summary identified 53 unique centre selection criteria. 78 protocols (60%) provided at least one criterion for centre selection, but only 31 (24%) protocols explicitly acknowledged generalisability. This is consistent with the survey findings (n = 70), where less than a third of participants reported generalisability as a key driver of centre selection in current practice. This contrasts with trialists' views on optimal practice, where generalisability in terms of clinical practice, population characteristics and economic results were prime considerations for 60% (n = 42), 57% (n = 40) and 46% (n = 32) of respondents, respectively. CONCLUSIONS: Centres are rarely enrolled in RCTs with an explicit view to external validity, although trialists acknowledge that incorporating generalisability in centre selection should ideally be more prominent. There is a need to operationalize 'generalisability' and incorporate it at the design stage of RCTs so that results are readily transferable to 'real world' practice

Health in times of uncertainty in the eastern Mediterranean region, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013. Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically. Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60–80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred. Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts.Ali H Mokdad ... Azmeraw T Amare ... et al

Search for nucleon decays with EXO-200

A search for instability of nucleons bound in $^{136}$Xe nuclei is reported with 223 kg$\cdot$yr exposure of $^{136}$Xe in the EXO-200 experiment. Lifetime limits of 3.3$\times 10^{23}$ and 1.9$\times 10^{23}$ yrs are established for nucleon decay to $^{133}$Sb and $^{133}$Te, respectively. These are the most stringent to date, exceeding the prior decay limits by a factor of 9 and 7, respectively

Deep Neural Networks for Energy and Position Reconstruction in EXO-200

We apply deep neural networks (DNN) to data from the EXO-200 experiment. In the studied cases, the DNN is able to reconstruct the relevant parameters - total energy and position - directly from raw digitized waveforms, with minimal exceptions. For the first time, the developed algorithms are evaluated on real detector calibration data. The accuracy of reconstruction either reaches or exceeds what was achieved by the conventional approaches developed by EXO-200 over the course of the experiment. Most existing DNN approaches to event reconstruction and classification in particle physics are trained on Monte Carlo simulated events. Such algorithms are inherently limited by the accuracy of the simulation. We describe a unique approach that, in an experiment such as EXO-200, allows to successfully perform certain reconstruction and analysis tasks by training the network on waveforms from experimental data, either reducing or eliminating the reliance on the Monte Carlo.Comment: Accepted version. 33 pages, 28 figure

Regional Hydroclimate Response to Stratospheric Sulfate Geoengineering and the Role of Stratospheric Heating

Geoengineering methods could potentially offset aspects of greenhouse gas‐driven climate change. However, before embarking on any such strategy, a comprehensive understanding of its impacts must be obtained. Here, a 20‐member ensemble of simulations with the Community Earth System Model with the Whole Atmosphere Community Climate Model as its atmospheric component is used to investigate the projected hydroclimate changes that occur when greenhouse gas‐driven warming, under a high emissions scenario, is offset with stratospheric aerosol geoengineering. Notable features of the late 21st century hydroclimate response, relative to present day, include a reduction in precipitation in the Indian summer monsoon, over much of Africa, Amazonia and southern Chile and a wintertime precipitation reduction over the Mediterranean. Over most of these regions, the soil desiccation that occurs with global warming is, however, largely offset by the geoengineering. A notable exception is India, where soil desiccation and an approximate doubling of the likelihood of monsoon failures occurs. The role of stratospheric heating in the simulated hydroclimate change is determined through additional experiments where the aerosol‐induced stratospheric heating is imposed as a temperature tendency, within the same model, under present day conditions. Stratospheric heating is found to play a key role in many aspects of projected hydroclimate change, resulting in a general wet‐get‐drier, dry‐get‐wetter pattern in the tropics and extratropical precipitation changes through midlatitude circulation shifts. While a rather extreme geoengineering scenario has been considered, many, but not all, of the precipitation features scale linearly with the offset global warming

Investigation of radioactivity-induced backgrounds in EXO-200

The search for neutrinoless double-beta decay (0{\nu}{\beta}{\beta}) requires extremely low background and a good understanding of their sources and their influence on the rate in the region of parameter space relevant to the 0{\nu}{\beta}{\beta} signal. We report on studies of various {\beta}- and {\gamma}-backgrounds in the liquid- xenon-based EXO-200 0{\nu}{\beta}{\beta} experiment. With this work we try to better understand the location and strength of specific background sources and compare the conclusions to radioassay results taken before and during detector construction. Finally, we discuss the implications of these studies for EXO-200 as well as for the next-generation, tonne-scale nEXO detector.Comment: 9 pages, 7 figures, 3 table