The challenges faced in the design, conduct and analysis of surgical randomised controlled trials

Randomised evaluations of surgical interventions are rare; some interventions have been widely adopted without rigorous evaluation. Unlike other medical areas, the randomised controlled trial (RCT) design has not become the default study design for the evaluation of surgical interventions. Surgical trials are difficult to successfully undertake and pose particular practical and methodological challenges. However, RCTs have played a role in the assessment of surgical innovations and there is scope and need for greater use. This article will consider the design, conduct and analysis of an RCT of a surgical intervention. The issues will be reviewed under three headings: the timing of the evaluation, defining the research question and trial design issues. Recommendations on the conduct of future surgical RCTs are made. Collaboration between research and surgical communities is needed to address the distinct issues raised by the assessmentof surgical interventions and enable the conduct of appropriate and well-designed trials.The Health Services Research Unit is funded by the Scottish Government Health DirectoratesPeer reviewedPublisher PD

COMAP Early Science: VIII. A Joint Stacking Analysis with eBOSS Quasars

We present a new upper limit on the cosmic molecular gas density at z = 2.4 − 3.4 obtained using the first year of observations from the CO Mapping Array Project (COMAP). COMAP data cubes are stacked on the 3D positions of 243 quasars selected from the Extended Baryon Oscillation SpectroscopicSurvey (eBOSS) catalog, yielding a 95% upper limit for flux from CO(1-0) line emission of 0.129 Jykm/s. Depending on the balance of the emission between the quasar host and its environment, this value can be interpreted as an average CO line luminosity L′CO of eBOSS quasars of ≤ 1.26 × 1011 K km pc2s−1, or an average molecular gas density ρH2 in regions of the universe containing a quasar of ≤ 1.52 × 108 M⊙ cMpc−3. The L′ CO upper limit falls among CO line luminosities obtained fromindividually-targeted quasars in the COMAP redshift range, and the ρH2 value is comparable to upper limits obtained from other Line Intensity Mapping (LIM) surveys and their joint analyses. Further, we forecast the values obtainable with the COMAP/eBOSS stack after the full 5-year COMAP Pathfinder survey. We predict that a detection is probable with this method, depending on the CO properties of the quasar sample. Based on the achieved sensitivity, we believe that this technique of stacking LIM data on the positions of traditional galaxy or quasar catalogs is extremely promising, both asa technique for investigating large galaxy catalogs efficiently at high redshift and as a technique for bolstering the sensitivity of LIM experiments, even with a fraction of their total expected survey data

COMAP Early Science: VIII. A Joint Stacking Analysis with eBOSS Quasars

We present a new upper limit on the cosmic molecular gas density at $z=2.4-3.4$ obtained using the first year of observations from the CO Mapping Array Project (COMAP). COMAP data cubes are stacked on the 3D positions of 282 quasars selected from the Extended Baryon Oscillation Spectroscopic Survey (eBOSS) catalog, yielding a 95% upper limit for flux from CO(1-0) line emission of 0.210 Jy km/s. Depending on the assumptions made, this value can be interpreted as either an average CO line luminosity $L'_\mathrm{CO}$ of eBOSS quasars of $\leq 7.30\times10^{10}$ K km pc$^2$ s$^{-1}$, or an average molecular gas density $\rho_\mathrm{H_2}$ in regions of the universe containing a quasar of $\leq 2.02\times10^8$ M$_\odot$ cMpc$^{-3}$. The $L'_\mathrm{CO}$ upper limit falls among CO line luminosities obtained from individually-targeted quasars in the COMAP redshift range, and the $\rho_\mathrm{H_2}$ value is comparable to upper limits obtained from other Line Intensity Mapping (LIM) surveys and their joint analyses. Further, we forecast the values obtainable with the COMAP/eBOSS stack after the full 5-year COMAP Pathfinder survey. We predict that a detection is probable with this method, depending on the CO properties of the quasar sample. Based on these achieved sensitivities, we believe that this technique of stacking LIM data on the positions of traditional galaxy or quasar catalogs is extremely promising, both as a technique for investigating large galaxy catalogs efficiently at high redshift and as a technique for bolstering the sensitivity of LIM experiments, even with a fraction of their total expected survey data.Comment: 15 pages, 8 figures. To be submitted to Ap

Chinese and white Canadian satisfaction and compliance with physicians

BACKGROUND: Patient satisfaction has become an important indicator of primary care and healthcare system performance. Ethnic disparities in patient satisfaction and compliance with physician care have been studied in several countries. However, this issue has not received significant attention in Canada. The unique characteristics of the Canadian healthcare system and ethnic population make it worthwhile to examine this issue in this population. Therefore, we conducted a survey among Chinese and Whites in a Canadian city to determine their reported satisfaction, and perceptions of physicians. METHODS: The survey was conducted in English, Mandarin and Cantonese in 2005 among Chinese and White Canadians, 18 years of age or older, who had visited at least one physician in Canada. RESULTS: We analyzed 746 Chinese and 711 Whites in the general practitioner (GP) visit group and 485 Chinese and 637 Whites in the specialist visit group. A lower proportion of Chinese compared to Whites reported that they were very satisfied or satisfied with GP (73.7% vs. 92.8%) and specialist care (75.5% vs. 85.6%) and the differences between the two groups remained after adjustment for demographic variables and chronic conditions (risk adjusted OR: 0.70, 95%CI: 0.42–1.18 for the GP visit group and OR: 0.77, 95%CI: 0.48–1.23 for the specialist visit group). A similar proportion of Chinese and Whites reported that they always followed a physician's advice (59.4% vs. 59.6% for the GP visit group and 67.2% vs. 62.8% for the specialist visit group). Non-English speaking Chinese and recent arrivals in Canada were less likely to be satisfied with GPs than Chinese born in Canada [risk adjusted OR: 0.5, 95%CI: 0.3–0.9, 0.2 and 0.1–0.7, respectively]. CONCLUSION: Chinese Canadians reported lower satisfaction with physicians and perceived physicians slightly more negatively than White Canadians. Particularly, Chinese with limited English and short length of stay in Canada were less satisfied than Canadian born Chinese

COMAP Early Science: VII. Prospects for CO Intensity Mapping at Reionization

We introduce COMAP-EoR, the next generation of the Carbon Monoxide Mapping Array Project aimed at extending CO intensity mapping to the Epoch of Reionization. COMAP-EoR supplements the existing 30 GHz COMAP Pathfinder with two additional 30 GHz instruments and a new 16 GHz receiver. This combination of frequencies will be able to simultaneously map CO(1--0) and CO(2--1) at reionization redshifts ($z\sim5-8$) in addition to providing a significant boost to the $z\sim3$ sensitivity of the Pathfinder. We examine a set of existing models of the EoR CO signal, and find power spectra spanning several orders of magnitude, highlighting our extreme ignorance about this period of cosmic history and the value of the COMAP-EoR measurement. We carry out the most detailed forecast to date of an intensity mapping cross-correlation, and find that five out of the six models we consider yield signal to noise ratios (S/N) $\gtrsim20$ for COMAP-EoR, with the brightest reaching a S/N above 400. We show that, for these models, COMAP-EoR can make a detailed measurement of the cosmic molecular gas history from $z\sim2-8$, as well as probe the population of faint, star-forming galaxies predicted by these models to be undetectable by traditional surveys. We show that, for the single model that does not predict numerous faint emitters, a COMAP-EoR-type measurement is required to rule out their existence. We briefly explore prospects for a third-generation Expanded Reionization Array (COMAP-ERA) capable of detecting the faintest models and characterizing the brightest signals in extreme detail.Comment: Paper 7 of 7 in series. 19 pages, 10 figures, to be submitted to Ap

COMAP Early Science: I. Overview

The CO Mapping Array Project (COMAP) aims to use line intensity mapping of carbon monoxide (CO) to trace the distribution and global properties of galaxies over cosmic time, back to the Epoch of Reionization (EoR). To validate the technologies and techniques needed for this goal, a Pathfinder instrument has been constructed and fielded. Sensitive to CO(1-0) emission from $z=2.4$-$3.4$ and a fainter contribution from CO(2-1) at $z=6$-8, the Pathfinder is surveying $12$ deg$^2$ in a 5-year observing campaign to detect the CO signal from $z\sim3$. Using data from the first 13 months of observing, we estimate $P_\mathrm{CO}(k) = -2.7 \pm 1.7 \times 10^4\mu\mathrm{K}^2 \mathrm{Mpc}^3$ on scales $k=0.051-0.62 \mathrm{Mpc}^{-1}$ - the first direct 3D constraint on the clustering component of the CO(1-0) power spectrum. Based on these observations alone, we obtain a constraint on the amplitude of the clustering component (the squared mean CO line temperature-bias product) of $\langle Tb\rangle^2<49$ $\mu$K$^2$ - nearly an order-of-magnitude improvement on the previous best measurement. These constraints allow us to rule out two models from the literature. We forecast a detection of the power spectrum after 5 years with signal-to-noise ratio (S/N) 9-17. Cross-correlation with an overlapping galaxy survey will yield a detection of the CO-galaxy power spectrum with S/N of 19. We are also conducting a 30 GHz survey of the Galactic plane and present a preliminary map. Looking to the future of COMAP, we examine the prospects for future phases of the experiment to detect and characterize the CO signal from the EoR.Comment: Paper 1 of 7 in series. 18 pages, 16 figures, submitted to Ap

COMAP Early Science: V. Constraints and Forecasts at z∼3z \sim 3

We present the current state of models for the $z\sim3$ carbon monoxide (CO) line-intensity signal targeted by the CO Mapping Array Project (COMAP) Pathfinder in the context of its early science results. Our fiducial model, relating dark matter halo properties to CO luminosities, informs parameter priors with empirical models of the galaxy-halo connection and previous CO(1-0) observations. The Pathfinder early science data spanning wavenumbers $k=0.051$-$0.62\,$Mpc$^{-1}$ represent the first direct 3D constraint on the clustering component of the CO(1-0) power spectrum. Our 95% upper limit on the redshift-space clustering amplitude $A_{\rm clust}\lesssim70\,\mu$K$^2$ greatly improves on the indirect upper limit of $420\,\mu$K$^2$ reported from the CO Power Spectrum Survey (COPSS) measurement at $k\sim1\,$Mpc$^{-1}$. The COMAP limit excludes a subset of models from previous literature, and constrains interpretation of the COPSS results, demonstrating the complementary nature of COMAP and interferometric CO surveys. Using line bias expectations from our priors, we also constrain the squared mean line intensity-bias product, $\langle{Tb}\rangle^2\lesssim50\,\mu$K$^2$, and the cosmic molecular gas density, $\rho_\text{H2}<2.5\times10^8\,M_\odot\,$Mpc$^{-3}$ (95% upper limits). Based on early instrument performance and our current CO signal estimates, we forecast that the five-year Pathfinder campaign will detect the CO power spectrum with overall signal-to-noise of 9-17. Between then and now, we also expect to detect the CO-galaxy cross-spectrum using overlapping galaxy survey data, enabling enhanced inferences of cosmic star-formation and galaxy-evolution history.Comment: Paper 5 of 7 in series. 17 pages + appendix and bibliography (30 pages total); 15 figures, 6 tables; accepted for publication in ApJ; v3 reflects the accepted version with minor changes and additions to tex

Neutrino Physics from the Cosmic Microwave Background and Large Scale Structure

This is a report on the status and prospects of the quantification of neutrino properties through the cosmological neutrino background for the Cosmic Frontier of the Division of Particles and Fields Community Summer Study long-term planning exercise. Experiments planned and underway are prepared to study the cosmological neutrino background in detail via its influence on distance-redshift relations and the growth of structure. The program for the next decade described in this document, including upcoming spectroscopic galaxy surveys eBOSS and DESI and a new Stage-IV CMB polarization experiment CMB-S4, will achieve sigma(sum m_nu) = 16 meV and sigma(N_eff) = 0.020. Such a mass measurement will produce a high significance detection of non-zero sum m_nu, whose lower bound derived from atmospheric and solar neutrino oscillation data is about 58 meV. If neutrinos have a minimal normal mass hierarchy, this measurement will definitively rule out the inverted neutrino mass hierarchy, shedding light on one of the most puzzling aspects of the Standard Model of particle physics --- the origin of mass. This precise a measurement of N_eff will allow for high sensitivity to any light and dark degrees of freedom produced in the big bang and a precision test of the standard cosmological model prediction that N_eff = 3.046.Astronom

Inflation Physics from the Cosmic Microwave Background and Large Scale Structure

Fluctuations in the intensity and polarization of the cosmic microwave background (CMB) and the large-scale distribution of matter in the universe each contain clues about the nature of the earliest moments of time. The next generation of CMB and large-scale structure (LSS) experiments are poised to test the leading paradigm for these earliest moments---the theory of cosmic inflation---and to detect the imprints of the inflationary epoch, thereby dramatically increasing our understanding of fundamental physics and the early universe. A future CMB experiment with sufficient angular resolution and frequency coverage that surveys at least 1% of the sky to a depth of 1 uK-arcmin can deliver a constraint on the tensor-to-scalar ratio that will either result in a 5-sigma measurement of the energy scale of inflation or rule out all large-field inflation models, even in the presence of foregrounds and the gravitational lensing B-mode signal. LSS experiments, particularly spectroscopic surveys such as the Dark Energy Spectroscopic Instrument, will complement the CMB effort by improving current constraints on running of the spectral index by up to a factor of four, improving constraints on curvature by a factor of ten, and providing non-Gaussianity constraints that are competitive with the current CMB bounds.Astronom