Comparing multiple competing interventions in the absence of randomized trials using clinical risk-benefit analysis

<p>Abstract</p> <p>Background</p> <p>To demonstrate the use of risk-benefit analysis for comparing multiple competing interventions in the absence of randomized trials, we applied this approach to the evaluation of five anticoagulants to prevent thrombosis in patients undergoing orthopedic surgery.</p> <p>Methods</p> <p>Using a cost-effectiveness approach from a clinical perspective (i.e. risk benefit analysis) we compared thromboprophylaxis with warfarin, low molecular weight heparin, unfractionated heparin, fondaparinux or ximelagatran in patients undergoing major orthopedic surgery, with sub-analyses according to surgery type. Proportions and variances of events defining risk (major bleeding) and benefit (thrombosis averted) were obtained through a meta-analysis and used to define beta distributions. Monte Carlo simulations were conducted and used to calculate incremental risks, benefits, and risk-benefit ratios. Finally, net clinical benefit was calculated for all replications across a range of risk-benefit acceptability thresholds, with a reference range obtained by estimating the case fatality rate - ratio of thrombosis to bleeding.</p> <p>Results</p> <p>The analysis showed that compared to placebo ximelagatran was superior to other options but final results were influenced by type of surgery, since ximelagatran was superior in total knee replacement but not in total hip replacement.</p> <p>Conclusions</p> <p>Using simulation and economic techniques we demonstrate a method that allows comparing multiple competing interventions in the absence of randomized trials with multiple arms by determining the option with the best risk-benefit profile. It can be helpful in clinical decision making since it incorporates risk, benefit, and personal risk acceptance.</p

The Institutional Design of Riparian Treaties: The Role of River Issues

International agreements governing rivers vary considerably in whether they contain institutional provisions for joint monitoring, conflict resolution, enforcement, and/or the delegation of authority to intergovernmental organizations. This article develops an explanation for why some river management treaties include more institutional provisions while others contain fewer, if any. The authors argue that certain types of issues related to river use—water quantity, water quality, and navigation—tend to be difficult to manage and prone to noncompliance. When forming treaties to address these specific issues, states will be more likely to include institutional provisions. The authors test the link between these river use issues and institutional design using a data set of 315 river treaties signed since 1950. The results show that highly contentious issues—and in particular water quantity and navigation—have a greater effect on the institutional design of river treaties than contextual and power politics factors.cooperation, conflict, water, international institutions, transboundary rivers

Wireless sensor systems for sense/decide/act/communicate.

After 9/11, the United States (U.S.) was suddenly pushed into challenging situations they could no longer ignore as simple spectators. The War on Terrorism (WoT) was suddenly ignited and no one knows when this war will end. While the government is exploring many existing and potential technologies, the area of wireless Sensor networks (WSN) has emerged as a foundation for establish future national security. Unlike other technologies, WSN could provide virtual presence capabilities needed for precision awareness and response in military, intelligence, and homeland security applications. The Advance Concept Group (ACG) vision of Sense/Decide/Act/Communicate (SDAC) sensor system is an instantiation of the WSN concept that takes a 'systems of systems' view. Each sensing nodes will exhibit the ability to: Sense the environment around them, Decide as a collective what the situation of their environment is, Act in an intelligent and coordinated manner in response to this situational determination, and Communicate their actions amongst each other and to a human command. This LDRD report provides a review of the research and development done to bring the SDAC vision closer to reality