Opening out and closing down: The treatment of uncertainty in transport planning’s forecasting paradigm

© 2019, The Author(s). Since the 1960s, development of the transport system has been framed by the notion of forecasting future demand. Yet the past decade or more appears to signal some significant changes to the role of travel in society which are having a material impact on how much people travel (and may travel in the future). Coupled with the potential for major technological changes and a range of climate adaptation scenarios, the future of mobility presents today’s decision making on transport strategy and investment with a broader set of uncertainties than has previously been considered. This paper examines current mainstream practice for incorporating uncertainty into decision-making, through an illustrative case study of the highly codified approaches of the Department for Transport in England. It deconstructs the issue by first focussing on different ways in which there is an opening out or acceptance of new uncertainties and how this creates a (wider) set of potential futures. It then turns to consider how this set of futures is used, or not, in decision-making, i.e. the process of closing down uncertainty to arrive at or at least inform a decision. We demonstrate that, because the range of uncertainties has broadened in scope and scale, the traditional technocratic approach of closing down decisions through sensitivity testing is at odds with the greater breadth now being called for at the opening out stage. We conclude that transport decision-making would benefit from a rebalancing of technical depth with analytical breadth. The paper outlines a plausible new approach to opening out and closing down that is starting to be applied in practice. This approach must be accompanied by an opening up of the processes by which technical advice for decisions are reached and how uncertainties are understood and negotiated

Use of malaria rapid diagnostic tests by community health workers in Afghanistan: cluster randomised trial

Background: The World Health Organisation (WHO) recommends parasitological diagnosis of malaria before treatment, but use of malaria rapid diagnostic tests (mRDTs) by community health workers (CHWs) has not been fully tested within health services in south and central Asia. mRDTs could allow CHWs to diagnose malaria accurately, improving treatment of febrile illness. Methods: A cluster randomised trial in community health services was undertaken in Afghanistan. The primary outcome was the proportion of suspected malaria cases correctly treated for polymerase chain reaction (PCR)-confirmed malaria and PCR negative cases receiving no antimalarial drugs measured at the level of the patient. CHWs from 22 clusters (clinics) received standard training on clinical diagnosis and treatment of malaria; 11 clusters randomised to the intervention arm received additional training and were provided with mRDTs. CHWs enrolled cases of suspected malaria, and the mRDT results and treatments were compared to blind-read PCR diagnosis. Results: In total, 256 CHWs enrolled 2400 patients with 2154 (89.8%) evaluated. In the intervention arm, 75.3% (828/1099) were treated appropriately vs. 17.5% (185/1055) in the control arm (cluster adjusted risk ratio: 3.72, 95% confidence interval 2.40–5.77; p < 0.001). In the control arm, 85.9% (164/191) with confirmed Plasmodium vivax received chloroquine compared to 45.1% (70/155) in the intervention arm (p < 0.001). Overuse of chloroquine in the control arm resulted in 87.6% (813/928) of those with no malaria (PCR negative) being treated vs. 10.0% (95/947) in the intervention arm, p < 0.001. In the intervention arm, 71.4% (30/42) of patients with P. falciparum did not receive artemisinin-based combination therapy, partly because operational sensitivity of the RDTs was low (53.2%, 38.1–67.9). There was high concordance between recorded RDT result and CHW prescription decisions: 826/950 (87.0%) with a negative test were not prescribed an antimalarial. Co-trimoxazole was prescribed to 62.7% of malaria negative patients in the intervention arm and 15.0% in the control arm. Conclusions: While introducing mRDT reduced overuse of antimalarials, this action came with risks that need to be considered before use at scale: an appreciable proportion of malaria cases will be missed by those using current mRDTs. Higher sensitivity tests could be used to detect all cases. Overtreatment with antimalarial drugs in the control arm was replaced with increased antibiotic prescription in the intervention arm, resulting in a probable overuse of antibiotics. Trial registration: ClinicalTrials.gov, NCT01403350. Prospectively registered

Success or failure of critical steps in community case management of malaria with rapid diagnostic tests: a systematic review

Background: Malaria still causes high morbidity and mortality around the world, mainly in sub-Saharan Africa. Community case management of malaria (CCMm) by community health workers (CHWs) is one of the strategies to combat the disease by increasing access to malaria treatment. Currently, the World Health Organization recommends to treat only confirmed malaria cases, rather than to give presumptive treatment. Objectives. This systematic review aims to provide a comprehensive overview of the success or failure of critical steps in CCMm with rapid diagnostic tests (RDTs). Methods. The databases of Medline, Embase, the Cochrane Library, the library of the \u27Malaria in Pregnancy\u27 consortium, and Web of Science were used to find studies on CCMm with RDTs in SSA. Studies were selected according to inclusion and exclusion criteria, subsequently risk of bias was assessed and data extracted. Results: 27 articles were included. CHWs were able to correctly perform RDTs, although specificity levels were variable. CHWs showed high adherence to test results, but in some studies a substantial group of RDT negatives received treatment. High risk of bias was found for morbidity and mortality studies, therefore, effects on morbidity and mortality could not be estimated. Uptake and acceptance by the community was high, however negative-tested patients did not always follow up referral advice. Drug or RDT stock-outs and limited information on CHW motivation are bottlenecks for sustainable implementation. RDT-based CCMm was found to be cost effective for the correct treatment of malaria in areas with low to medium malaria prevalence, but study designs were not optimal. Discussion. Trained CHWs can deliver high quality care for malaria using RDTs. However, lower RDT specificity could lead to missed diagnoses of non-malarial causes of fever. Other threats for CCMm are non-adherence to negative test results and low referral completion. Integrated CCM may solve some of these issues. Unfortunately, morbidity and mortality are not adequately investigated. More information is needed about influencing sociocultural aspects, CHW motivation and stock supply. Conclusion: CCMm is generally well executed by CHWs, but there are several barriers for its success. Integrated CCM may overcome some of these barriers

Optimum force magnitude for orthodontic tooth movement: a systematic literature review.

The aim of this study was to perform a meta-analysis of the literature concerning the optimal force or range of forces for orthodontic tooth movement. Over 400 articles both on human research and animal experiments were found in Medline and by hand searching of main orthodontic and dental journals. Articles on animal experiments were in the majority. A wide range of animal species such as rat, cat, rabbit, beagle dog, monkey, mouse, and guinea pig were used. Besides variation in species, there was also a wide range of force magnitudes, teeth under study, directions of tooth movement, duration of experimental period, and force reactivation. Furthermore, hardly any experiments were reported that provide information on the relation between the velocity of tooth movement and the magnitude of the applied force. Data from human research on the efficiency of orthodontic tooth movement appeared to be very limited. The large variation in data from current literature made it impossible to perform a meta-analysis. Therefore, we have systematically reviewed the literature. It appeared that no evidence about the optimal force level in orthodontics could be extracted from literature. Well-controlled clinical studies and more standardized animal experiments in the orthodontic field are required to provide more insight into the relation between the applied force and the rate of tooth movement

Immunohistochemical evaluation of osteoclast recruitment during experimental tooth movement in young and adult rats.

Contains fulltext : 47588.pdf (publisher's version ) (Closed access)OBJECTIVE: Orthodontic tooth movement starts slower in adults than in juveniles, but the rate of tooth movement in later phases is the same in both age groups. The hypotheses to be tested are that these phenomena are related to slower osteoclast recruitment in adults than in juveniles, but that in later phases the osteoclast numbers are the same in both age groups. DESIGN: Standardized orthodontic tooth movement was performed in two groups of 30 rats, aged 6 weeks and 9-12 months, respectively. All maxillary molars at one side were together moved mesially by a continuous force of 10 cN. The other side served as a control. After 1, 2, 4, 8 and 12 weeks, groups of animals were killed. After ED1 staining osteoclast numbers at the mesial and distal sides of selected roots were counted. RESULTS: At the compression sides osteoclast numbers increased in both age groups. In young rats, a maximum was reached at 2 weeks, in adults at 4 weeks. In later phases of tooth movement, the number of osteoclasts in the adults was approximately twice as high as in the juveniles, while the rate of tooth movement was the same. A positive correlation between the rate of tooth movement and osteoclast numbers was found only in young rats. CONCLUSIONS: Orthodontic forces induce faster osteoclast recruitment in young than in adult rats and more osteoclasts are needed to achieve a certain rate of tooth movement in adult than in young rats

The rat as a model for orthodontic tooth movement--a critical review and a proposed solution.

Contains fulltext : 57139.pdf (publisher's version ) (Closed access)The aims of this study were to perform a systematic review of the use of rats as a model for experimental tooth movement, to give a critical evaluation of the use of elastics as a force delivery system, and to describe a newly designed well-defined model for tooth movement in rats. The literature from 1981 to 2002 indicates that in 57 per cent of animal studies on orthodontic tooth movement, rats were used, but in many of these investigations the experimental set-up was poorly documented. Only three of the 159 studies fulfilled the inclusion criteria for a good model: a force magnitude of less than 20 cN; moving molar(s) mesially; an experimental duration longer than 2 weeks; and no extra experimental condition such as drug intervention. As more than one-quarter of the studies on tooth movement in rats used elastics to produce an orthodontic force, and as the forces they produced and their force decay during decompression are unknown, their mechanical characteristics on decompression were tested. Elastics stored under dry conditions or in water showed significant force decay from around 45 N to almost 0 N within the first 0.2 mm of decompression. With regard to the above-mentioned shortcomings of using rats as a model for tooth movement, a newly designed experimental appliance for tooth movement in rats was evaluated. It proved to be stable and simple and able to deliver a continuous and constant force as low as 10 cN on all three molars together during an experimental period of 12 weeks without interference in animal welfare, and was able to compensate for the effects of molar distal drift and continuous incisor eruption

Effect of duration of force application on blood vessels in young and adult rats.

Contains fulltext : 70428.pdf (publisher's version ) (Closed access)INTRODUCTION: Age effects on orthodontically induced periodontal vascular reactions have not been studied. The aim of the present study was to test the hypothesis that prolonged tooth movement induces age-related increases in periodontal vascularity. METHODS: A standardized orthodontic appliance was placed in 2 groups of 30 rats aged 6 weeks and 9 to 12 months. At 1, 2, 4, 8, and 12 weeks, animals were killed. Blood vessels (BV) were identified based on their morphology and by immunohistochemical staining for alpha-smooth muscle actin. At each study region, surface areas (SA) of the periodontal ligament space and each BV were measured; BV mean SA, BV relative SA (the summed BV SA as a percentage of the periodontal ligament SA), and BV numbers were calculated. RESULTS: Pressure and tension regions showed similar vascular changes. Young rats had lower BV relative SA and BV mean SA in the early phase of force application (< 4 weeks); this increased in the late phase, reaching the same level as adult rats. In the late phase (4-12 weeks), young rats had increases of both small- and large-sized BV that did not affect the BV mean SA; adult rats had an increase of small-sized BV only; this resulted in decreased BV mean SA. CONCLUSIONS: The hypothesis was confirmed that prolonged tooth movement increases periodontal vascularity, which is age related. These results suggest that clinicians should consider age-related difference in tissue reactions during orthodontic tooth movement