Improving the external validity of clinical trials: the case of multiple chronic conditions

The U.S. Department of Health and Human Services vision and strategic framework on multiple chronic conditions (MCCs) incorporates recommendations designed to facilitate research that will improve our knowledge about interventions and systems that will benefit individuals with MCCs (or multimorbidity). The evidence base supporting the management of patients with MCCs will be built both through intervention trials specifically designed to address multimorbidity and identification of MCCs in participants across the clinical trial range. This article specifically focuses on issues relating to external validity with specific reference to trials involving patients with MCCs. The exclusion of such patients from clinical trials has been well documented. Randomized control trials (RCTs) are considered the “gold standard” of evidence, but may have drawbacks in relation to external validity, particularly in relation to multimorbidity. It may, therefore, be necessary to consider a broader range of research methods that can provide converging evidence on intervention effects to address MCCs. Approaches can also be taken to increase the usefulness of RCTs in general for providing evidence to inform multimorbidity management. Additional improvements to RCTs would include better reporting of inclusion and exclusion criteria and participant characteristics in relation to MCCs. New trials should be considered in terms of how they will add to the existing evidence base and should inform how interventions may work in different settings and patient groups. Research on treatments and interventions for patients with MCCs is badly needed. It is important that this research includes patient-centered measures and that generalizability issues be explicitly addressed.Journal of Comorbidity 2013;3(2)30–3

Asylum in Practice: Successes, Failures, and the Challenges Ahead

The Workshop on Refugee and Asylum Policy in Practice in Europe and North America was organized to facilitate a transatlantic dialogue aimed at understanding just how well these asylum systems are balancing the dual goals. The Workshop was convened by the Institute for the Study of International Migration (ISIM) of Georgetown University and the Center for the Study of Immigration, Integration and Citizenship Policies (CEPIC) of the Centre Nationale de Recherche Scientifique, with the support of the German Marshall Fund of the United States. It was held on July 1-3, 1999, at Oxford University. The workshop examined key issues as to the workings of the U.S. and European asylum systems: decision making on claims, deterrence of abuse, independent review, return of rejected asylum seekers, scope of the refugee concept, social rights and employment, international cooperation, and data and evaluation. In this opening paper, we explain the significance of these issues and raise central questions about them

Palestinian Refugees in Gaza

Events since Arthur Helton\u27s death - including the change in leadership of the Palestinian Authority and the Israeli proposal for disengagement from Gaza make it even timelier to examine some practical solutions. For improving Palestinian lives in the short term, much can be learned from the approaches taken in other refugee situations. This Article begins with background information on Palestinian refugees in Gaza. It then discusses Israeli plans for disengagement from Gaza. In the following section, the Article reviews options for addressing the problems faced by Palestinian refugees in Gaza, utilizing the broader literature devoted to the integration of refugees and displaced persons in post-conflict and post-occupation societies. It concludes with an agenda of action for the international community, Palestinian Authority, and Israel

Temporary Protection: Towards a New Regional and Domestic Framework

During the past thirty-five years, the United States has seen the direct influx of thousands of individuals leaving politically unstable countries. While some seeking entry have proved themselves to be refugees and obtained permanent protection in the United States, far more, including a large number of people fleeing civil war, natural disasters, or comparable forms of upheaval in their home countries, have failed to demonstrate that they would be targets of persecution. Yet, their return to their home countries has been complicated by the very circumstances that led to their flight: conflict, violence, and repression. Over time, the United States developed a series of ad hoc responses that protected such individuals, culminating in the Immigration Act of 1990 (“IMMACT”), which provided legislative authority for Temporary Protected Status (“TPS”). Nevertheless, after eight years, many problems remain in the application of the law. Solving these problems will contribute both to better immigration control and more humane responses to future crises. Current policies fail on two accounts. First, the temporary protection provision in the law generally has failed to protect the vast majority of those in danger as a crisis develops and unfolds. If the United States government protects significant numbers at all, protection is provided outside the confines of the United States. Even so, the mechanisms for responding extraterritorially are not well developed. Second, current policies regarding protection in the United States do not provide the control mechanisms to ensure that protection is not abused and that return, when appropriate, is effected. The choice to admit people for temporary protection has been a difficult one for the United States for two main reasons: the lack of control over entry; and the inability to implement a fair but firm end game. These constraints together with the fear of litigation challenging domestic protection regimes have led policymakers to keep protection seekers offshore, such as on Guantanamo, or to return them directly to countries they fled without providing an opportunity for them to present requests for protection. But not having a fully developed regional or domestic capability for addressing these complex movements comes at a considerable cost. Estimates for the agency costs of handling the 1994 Cuban exodus through the use of offshore safe havens were more than $500 million. Further, an immigration system that cannot fairly and efficiently process protection seekers lacks credibility for which it pays a significant public cost

Ion Charge States in the Fast Solar Wind: New Data Analysis and Theoretical Refinements

We present a further investigation into the increased ionization observed in element charge states in the fast solar wind compared to its coronal hole source regions. Once ions begin to be perpendicularly heated by ion cyclotron waves and execute large gyro-orbits, density gradients in the flow can excite lower hybrid waves that then damp by heating electrons in the parallel direction. We give further analysis of charge state data from polar coronal holes at solar minimum and maximum, and also from equatorial coronal holes. We also consider further the damping of lower hybrid waves by ions and the effect of non-Maxwellian electron distribution functions on the degree of increased ionization, both of which appear to be negligible for the solar wind case considered here. We also suggest that the density gradients required to heat electrons sufficiently to further ionize the solar wind can plausibly result from the turbulent cascade of MHD waves.Comment: 27 pages, accepted by Ap

Ecodriving and Carbon Footprinting: Understanding How Public Education Can Reduce Greenhouse Gas Emissions and Fuel Use

Ecodriving is a collection of changes to driving behavior and vehicle maintenance designed to impact fuel consumption and greenhouse gas (GHG) emissions in existing vehicles. Because of its promise to improve fuel economy within the existing fleet, ecodriving has gained increased attention in North America. One strategy to improve ecodriving is through public education with information on how to ecodrive. This report provides a review and study of ecodriving from several angles. The report offers a literature review of previous work and programs in ecodriving across the world. In addition, researchers completed interviews with experts in the field of public relations and public message campaigns to ascertain best practices for public campaigns. Further, the study also completed a set of focus groups evaluating consumer response to a series of websites that displayed ecodriving information. Finally, researchers conducted a set of surveys, including a controlled stated-response study conducted with approximately 100 University of California, Berkeley faculty, staff, and students, assessing the effectiveness of static ecodriving web-based information as well as an intercept clipboard survey in the San Francisco Bay Area. The stated-response study consisted of a comparison of the experimental and control groups. It found that exposure to ecodriving information influenced people’s driving behavior and some maintenance practices. The experimental group’s distributional shift was statistically significant, particularly for key practices including: lower highway cruising speed, driving behavior adjustment, and proper tire inflation. Within the experimental group (N = 51), fewer respondents significantly changed their maintenance practices (16%) than the majority that altered some driving practices (71%). This suggests intentionally altering driving behavior is easier than planning better maintenance practices. While it was evident that not everyone modifies their behavior as a result of reviewing the ecodriving website, even small shifts in behavior due to inexpensive information dissemination could be deemed cost effective in reducing fuel consumption and emissions

Double-standards in reporting of risk and responsibility for sexual health: a qualitative content analysis of negatively toned UK newsprint articles

Background: The need to challenge messages that reinforce harmful negative discourses around sexual risk and responsibility is a priority in improving sexual health. The mass media are an important source of information regularly alerting, updating and influencing public opinions and the way in which sexual health issues are framed may play a crucial role in shaping expectations of who is responsible for sexual health risks and healthy sexual practices. Methods: We conducted an in-depth, qualitative analysis of 85 negatively toned newspaper articles reporting on sexual health topics to examine how risk and responsibility have been framed within these in relation to gender. Articles published in 2010 in seven UK and three Scottish national newspapers were included. A latent content analysis approach was taken, focusing on interpreting the underlying meaning of text. Results: A key theme in the articles was men being framed as a risk to women's sexual health, whilst it was part of a women's role to "resist" men's advances. Such discourses tended to portray a power imbalance in sexual relationships between women and men. A number of articles argued that it was women who needed to take more responsibility for sexual health. Articles repeatedly suggested that women and teenage girls in particular, lacked the skills and confidence to negotiate safer sex and sex education programmes were often presented as having failed. Men were frequently portrayed as being more promiscuous and engaging in more risky sexual health behaviours than women, yet just one article drew attention to the lack of focus on male responsibility for sexual health. Gay men were used as a bench mark against which rates were measured and framed as being a risk and at risk Conclusions: The framing of men as a risk to women, whilst women are presented at the same time as responsible for patrolling sexual encounters, organising contraception and preventing sexual ill health reinforces gender stereotypes and undermines efforts to promote a collective responsibility for sexual health. This has implications for sexual ill health prevention and could continue to reinforce a negative culture around sex, relationships and sexual health in the UK

Bikesharing and Bicycle Safety

The growth of bikesharing in the United States has had a transformative impact on urban transportation. Major cities have established large bikesharing systems, including Boston, Chicago, Denver, Minneapolis-Saint Paul, New York City, Salt Lake City, the San Francisco Bay Area, Seattle, Washington DC, and others. These systems began operating as early as 2010, and no fatalities have occurred within the US as of this writing. However, three have happened in North America—two in Canada and one in Mexico. Bikesharing has some qualities that appear inherently unsafe for bicyclists. Most prominently, helmet usage is documented to be quite low in most regions. Bikesharing is also used by irregular bicyclists who are less familiar with the local terrain. In this study, researchers take a closer look at bikesharing safety from qualitative and quantitative perspectives. Through a series of four focus groups, they discussed bikesharing usage and safety with bikesharing members and nonmembers in the Bay Area. They further engaged experts nationwide from a variety of fields to evaluate their opinions and perspectives on bikesharing and safety. Finally, researchers conducted an analysis of bicycle and bikesharing activity data, as well as bicycle and bikesharing collisions to evaluate injury rates associated with bikesharing when compared with benchmarks of personal bicycling. The data analysis found that collision and injury rates for bikesharing are lower than previously computed rates for personal bicycling. Experts and focus group participants independently pointed to bikesharing rider behavior and bikesharing bicycle design as possible factors. In particular, bikesharing bicycles are generally designed in ways that promote stability and limited speeds, which mitigate the conditions that contribute to collisions. Data analysis also explored whether there was evidence of a “safety in numbers benefit” that resulted from bikesharing activity. However, no significant impact from bikesharing activity on broader bicycle collisions could be found within the regions in which they operate. Discussion and recommendations are presented in the conclusion

Report on the Workshop on Refugee and Asylum Policy in Practice in Europe and North America

Western nations have struggled to accomplish the dual goals of refugee and asylum policies: (1) identifying and protecting Convention refugees as well as those fleeing civil conflict; and (2) controlling for abuse. The Workshop on Refugee and Asylum Policy in Practice in Europe and North America was organized to facilitate a transatlantic dialogue to explore just how well these asylum systems are balancing the dual goals. The workshop exa!llined key elements of the U.S. and European asylum systems: decision making on claims, deterrence of abuse, independent review, return of rejected asylum seekers, scope of the refugee concept, social rights and employment, international cooperation, and data and evaluation. The Workshop was convened by the Institute for the Study of International Migration (ISIM) of Georgetown University and the Center for the Study of Immigration, Integration and Citizenship Policies (CEPIC) of the Centre Nationale de Recherche Scientifique, with the support of the German Marshall Fund of the United States. It was held on July 1-3, 1999, at Oxford University. Workshop participants included government officials, scholars, and representatives from non-governmental organizations (NGOs) actively involved in analyzing and implementing refugee and asylum policies. This report outlines the major points of discussion and the areas of consensus at the Workshop, and emphasizes the issues in need of further analysis and agreement. Through this report, the Workshop seeks to encourage further discussion on refugee and asylum policies in practice in order to clarify, develop, and improve the existing mechanisms for protection

El estado de la evidencia

Los investigadores aún tienen mucho trabajo por hacer no sólo para comprender la migración inducida por el clima y los desastres, sino también para transmitir sus conocimientos para el uso de responsables políticos y profesionales