How to assess the external validity of therapeutic trials: a conceptual approach

Background External validity of study results is an important issue from a clinical point of view. From a methodological point of view, however, the concept of external validity is more complex than it seems to be at first glance. Methods Methodological review to address the concept of external validity. Results External validity refers to the question whether results are generalizable to persons other than the population in the original study. The only formal way to establish the external validity would be to repeat the study for that specific target population. We propose a three-way approach for assessing the external validity for specified target populations. (i) The study population might not be representative for the eligibility criteria that were intended. It should be addressed whether the study population differs from the intended source population with respect to characteristics that influence outcome. (ii) The target population will, by definition, differ from the study population with respect to geographical, temporal and ethnical conditions. Pondering external validity means asking the question whether these differences may influence study results. (iii) It should be assessed whether the study's conclusions can be generalized to target populations that do not meet all the eligibility criteria. Conclusion Judging the external validity of study results cannot be done by applying given eligibility criteria to a single target population. Rather, it is a complex reflection in which prior knowledge, statistical considerations, biological plausibility and eligibility criteria all have place.

Body Mass Index and Cancer Risk: The Evidence for Causal Association

Increased body mass index (BMI), as an approximation of body adiposity, is a risk factor for developing several adult malignancies. To quantify these risks, we reported a comprehensive systematic review (Lancet 2008; 371: 569-78) of prospective observational studies determining associations between BMI and risk of incident cancer for 20 cancer types. We demonstrated that associations are: (i) sex-specific; (ii) exist for a wider range of malignancies than previously thought; and (iii) are broadly consistent across geographic populations. In the present paper, we tested these data against the Bradford-Hill criteria of causal association, and argue that the available data support strength of association, consistency, specificity, temporality, biological gradient, plausibility, coherence and probably analogy. However, the experimental evidence supporting reversibility is currently lacking, though indirect evidence from longitudinal data in cohort studies and long-term follow-up post-bariatric surgery is emerging. We additionally assessed these data against appropriate adjustment for available confounding factors; measurement error and study design; and residual confounding; and found lack of alternative explanations. We conclude that there is considerable evidence to support a causal association between BMI and risk for many cancer types, but in order to establish the role of weight control in cancer prevention, there is a need to develop trial frameworks in which to better test reversibility.

[Pain disorders in traumatized individuals - neurophysiology and clinical presentation]

This overview portrays the salient physiological mechanisms being involved in the clinical manifestation of chronic pain in traumatized patients. A «hypermnesia-hyperarousal-model» is purported to support the neurophysiologic plausibility of the trauma-pain-relationship. We discuss seven characteristic clinical pain entities which alone or in combination can be found in patients with a previous psychological trauma.

[Investigation of abortions and other animal health problems in relation to vaccination against Bluetongue virus in 2009]

By the distribution of a questionnaire between all Swiss cattle practitioners it was possible to investigate abortions and other animal health problems related to Bluetongue vaccination 2009. The questionnaire helped to obtain plausibility and timely relation of the reported disorders. 58 abortions in cattle and different herd health problems could be examined. Because there is no possibility to show that a vaccination itself leads to an abortion the results of proven causes of abortions prior and after Bluetongue vaccination were compared regarding their diagnosis. Due to the fact that diagnosis and solving rate of abortions did not differ before and after vaccination, the vaccination itself cannot be responsible for the abortions. Evaluation of different herd health problems showed that Bluetongue vaccination was not responsible for these disorders which often existed already prior to vaccination. Herd health problems generally have multifactorial causes what makes it difficult to asses the effect of Bluetongue vaccination in some cases.

Information Integration Theory and the Construction of Individually Perceived Group Efficacy

According to Bandura (1997) efficacy beliefs are a primary determinant of motivation. Still, very little is known about the processes through which people integrate situational factors to form efficacy beliefs (Myers & Feltz, 2007). The aim of this study was to gain insight into the cognitive construction of subjective group-efficacy beliefs. Only with a sound understanding of those processes is there a sufficient base to derive psychological interventions aimed at group-efficacy beliefs. According to cognitive theories (e.g., Miller, Galanter, & Pribram, 1973) individual group-efficacy beliefs can be seen as the result of a comparison between the demands of a group task and the resources of the performing group. At the center of this comparison are internally represented structures of the group task and plans to perform it. The empirical plausibility of this notion was tested using functional measurement theory (Anderson, 1981). Twenty-three students (M = 23.30 years; SD = 3.39; 35 % females) of the University of Bern repeatedly judged the efficacy of groups in different group tasks. The groups consisted of the subjects and another one to two fictive group members. The latter were manipulated by their value (low, medium, high) in task-relevant abilities. Data obtained from multiple full factorial designs were structured with individuals as second level units and analyzed using mixed linear models. The task-relevant abilities of group members, specified as fixed factors, all had highly significant effects on subjects’ group-efficacy judgments. The effect sizes of the ability factors showed to be dependent on the respective abilities’ importance in a given task. In additive tasks (Steiner, 1972) group resources were integrated in a linear fashion whereas significant interaction between factors was obtained in interdependent tasks. The results also showed that people take into account other group members’ efficacy beliefs when forming their own group-efficacy beliefs. The results support the notion that personal group-efficacy beliefs are obtained by comparing the demands of a task with the performing groups’ resources. Psychological factors such as other team members’ efficacy beliefs are thereby being considered task relevant resources and affect subjective group-efficacy beliefs. This latter finding underlines the adequacy of multidimensional measures. While the validity of collective efficacy measures is usually estimated by how well they predict performances, the results of this study allow for a somewhat internal validity criterion. It is concluded that Information Integration Theory holds potential to further help understand people’s cognitive functioning in sport relevant situations.

The Swiss Neonatal Quality Cycle, a monitor for clinical performance and tool for quality improvement

BACKGROUND We describe the setup of a neonatal quality improvement tool and list which peer-reviewed requirements it fulfils and which it does not. We report on the so-far observed effects, how the units can identify quality improvement potential, and how they can measure the effect of changes made to improve quality. METHODS Application of a prospective longitudinal national cohort data collection that uses algorithms to ensure high data quality (i.e. checks for completeness, plausibility and reliability), and to perform data imaging (Plsek's p-charts and standardized mortality or morbidity ratio SMR charts). The collected data allows monitoring a study collective of very low birth-weight infants born from 2009 to 2011 by applying a quality cycle following the steps 'guideline - perform - falsify - reform'. RESULTS 2025 VLBW live-births from 2009 to 2011 representing 96.1% of all VLBW live-births in Switzerland display a similar mortality rate but better morbidity rates when compared to other networks. Data quality in general is high but subject to improvement in some units. Seven measurements display quality improvement potential in individual units. The methods used fulfil several international recommendations. CONCLUSIONS The Quality Cycle of the Swiss Neonatal Network is a helpful instrument to monitor and gradually help improve the quality of care in a region with high quality standards and low statistical discrimination capacity.

The year-long unprecedented European heat and drought of 1540 – a worst case

The heat waves of 2003 in Western Europe and 2010 in Russia, commonly labelled as rare climatic anomalies outside of previous experience, are often taken as harbingers of more frequent extremes in the global warming-influenced future. However, a recent reconstruction of spring–summer temperatures for WE resulted in the likelihood of significantly higher temperatures in 1540. In order to check the plausibility of this result we investigated the severity of the 1540 drought by putting forward the argument of the known soil desiccation-temperature feedback. Based on more than 300 first-hand documentary weather report sources originating from an area of 2 to 3 million km2, we show that Europe was affected by an unprecedented 11-month-long Megadrought. The estimated number of precipitation days and precipitation amount for Central and Western Europe in 1540 is significantly lower than the 100-year minima of the instrumental measurement period for spring, summer and autumn. This result is supported by independent documentary evidence about extremely low river flows and Europe-wide wild-, forest- and settlement fires. We found that an event of this severity cannot be simulated by state-of-the-art climate models.

Eine tragfähige Datenbrücke – Phänologische Beobachtungen im Amtsblatt des Kantons Schaffhausen 1876–1950

The international standardisation of national meteorological networks in the late nineteenth century excluded biotic and abiotic observations from the objects to be henceforth published in the yearbooks. Skilled amateurs being in charge of three meteorological stations in Canton Schaffhausen (Switzerland) and their successors managed to continuously publish phenological observations gathered in the station environment alongside with meteorological data in the official gazette of this Canton from 1876 to 1950, i.e. up to the onset of phenological network observations in Switzerland. At least ten observations are available for 51 plant and animal phenological phases. Long series were assembled (N → = 30) for 14 plant phenological observations, among them for the first flowering of snowdrop (Galanthus nivalis), of hazel (Corylus avellana), of horse chestnut (Aesculus hippocastanum), of winter rye (Secale cereale) and of grape vine (Vitis vinifera) as well as the beginning of hay, winter rye and grape harvesting. Only the bare data were published without any metadata. The quality of 10 long series (N →=60) was checked by investigating the biographical and biological background of key observers and submitting their evidence to graphical (meteorological plausibility check of outliers) and statistical verification. The long term observers, mostly schoolteachers and high school professors, had a good knowledge of botany and the quality of their observations – disregarding obvious printing errors – is surprisingly good. A number of long series (seven) was completed with applicable data from the Swiss Phenological Network up to 2011. Besides anthropogenic shifts (beginning of hay and grape harvest) there is a contrast between a global warming-related earlier flowering of snowdrop and hazel and a later occurrence of grape vine flowering.

Hazard index maps for woody material recruitment and transport in alpine catchments

A robust and reliable risk assessment procedure for hydrologic hazards deserves particular attention to the role of transported woody material during flash floods or debris flows. At present, woody material transport phenomena are not systematically considered within the procedures for the elaboration of hazard maps. The consequence is a risk of losing prediction accuracy and of underestimating hazard impacts. Transported woody material frequently interferes with the sediment regulation capacity of open check dams and moreover, when obstruction phenomena at critical crosssections of the stream occur, inundations can be triggered. The paper presents a procedure for the determination of the relative propensity of mountain streams to the entrainment and delivery of recruited woody material on the basis of empirical indicators. The procedure provided the basis for the elaboration of a hazard index map for all torrent catchments of the Autonomous Province of Bolzano/Bozen. The plausibility of the results has been thoroughly checked by a backward oriented analysis on natural hazard events, documented since 1998 at the Department of Hydraulic Engineering of the aforementioned Alpine Province. The procedure provides hints for the consideration of the effects, induced by woody material transport, during the elaboration of hazard zone maps.

A variationist approach to the examination of insertion and deletion of /h/ in Kosraean English

I report on language variation in the unresearched variety of English emerging on Kosrae, Federated States of Micronesia. English is spoken as the inter-island lingua franca throughout Micronesia and has been the official language of FSM since gaining its independence in 1986, though still retaining close ties with the US through and economic “compact” agreement. I present here an analysis of a corpus of over 90 Kosraean English speakers, compiled during a three month fieldwork trip to the island in the Western Pacific. The 45 minute sociolinguistically sensitive recordings are drawn from a corpus of old and young, with varying levels of education and occupations, and off-island experiences. In the paper I analyse two variables. The first variable is the realisation of /h/, often subject to deletion in both L1 and L2 varieties of English. Such occurrences are commonly associated with Cockney English, but also found in Caribbean English and the postcolonial English of Australia. For example:  Male, 31: yeah I build their house their local huts and they pay me /h/ deletion is frequent in Kosraean English, but, perhaps expectedly, occurs slightly less among people with higher contact with American English, through having spent longer periods off island. The second feature under scrutiny is the variable epenthesis of [h] to provide a consonantal onset to vowel-initial syllables.  Male, 31: that guy is really hold now This practice is also found beyond Kosraean English. Previous studies find h-epenthesis arising in L1 varieties including Newfoundland and Tristan de Cunha English, while similar manifestations are identified in Francophone L2 learners of English. My variationist statistical analysis has shown [h] insertion:  to disproportionately occur intervocalically;  to be constrained by both speaker gender and age: older males are much more likely to epenthesis [h] in their speech;  to be more likely in the onset of stressed as opposed to unstressed syllables. In light of the findings of my analysis, I consider the relationship between h-deletion and h-epenthesis, the plausibility of hypercorrection as a motivation for the variation, and the potential influence of the substrate language, alongside sociolinguistic factors such as attitudes towards the US based on mobility. The analysis sheds light on the extent to which different varieties share this characteristic and the comparability of them in terms of linguistic constraints and attributes. Clarke, S. (2010). Newfoundland and Labrador English. Edinburgh: Edinburgh University Press Hackert, S. (2004). Urban Bahamian Creole: System and Variation. Varieties of English Around the World G32. Amsterdam: Benjamins Milroy, J. (1983). On the Sociolinguistic History of H-dropping in English in Current topics in English historical linguistics: Odense UP

Increasing Scientific Confidence in Adverse Outcome Pathways: Application of Tailored Bradford-Hill Considerations for Evaluating Weight of Evidence.

Systematic consideration of scientific support is a critical element in developing and, ultimately, using adverse outcome pathways (AOPs) for various regulatory applications. Though weight of evidence (WoE) analysis has been proposed as a basis for assessment of the maturity and level of confidence in an AOP, methodologies and tools are still being formalized. The Organization for Economic Co-operation and Development (OECD) Users' Handbook Supplement to the Guidance Document for Developing and Assessing AOPs (OECD 2014a; hereafter referred to as the OECD AOP Handbook) provides tailored Bradford-Hill (BH) considerations for systematic assessment of confidence in a given AOP. These considerations include (1) biological plausibility and (2) empirical support (dose-response, temporality, and incidence) for Key Event Relationships (KERs), and (3) essentiality of key events (KEs). Here, we test the application of these tailored BH considerations and the guidance outlined in the OECD AOP Handbook using a number of case examples to increase experience in more transparently documenting rationales for assigned levels of confidence to KEs and KERs, and to promote consistency in evaluation within and across AOPs. The major lessons learned from experience are documented, and taken together with the case examples, should contribute to better common understanding of the nature and form of documentation required to increase confidence in the application of AOPs for specific uses. Based on the tailored BH considerations and defining questions, a prototype quantitative model for assessing the WoE of an AOP using tools of multi-criteria decision analysis (MCDA) is described. The applicability of the approach is also demonstrated using the case example aromatase inhibition leading to reproductive dysfunction in fish. Following the acquisition of additional experience in the development and assessment of AOPs, further refinement of parameterization of the model through expert elicitation is recommended. Overall, the application of quantitative WoE approaches hold promise to enhance the rigor, transparency and reproducibility for AOP WoE determinations and may play an important role in delineating areas where research would have the greatest impact on improving the overall confidence in the AOP.

Redistribution of particles across the nucleus of comet 67P/Churyumov-Gerasimenko

Context. We present an investigation of the surface properties of areas on the nucleus of comet 67P/Churyumov-Gerasimenko. Aims. We aim to show that transport of material from one part of the cometary nucleus to another is a significant mechanism that influences the appearance of the nucleus and the surface thermal properties. Methods. We used data from the OSIRIS imaging system onboard the Rosetta spacecraft to identify surface features on the nucleus that can be produced by various transport mechanisms. We used simple calculations based on previous works to establish the plausibility of dust transport from one part of the nucleus to another. Results. We show by observation and modeling that "airfall" as a consequence of non-escaping large particles emitted from the neck region of the nucleus is a plausible explanation for the smooth thin deposits in the northern hemisphere of the nucleus. The consequences are also discussed. We also present observations of aeolian ripples and ventifacts. We show by numerical modeling that a type of saltation is plausible even under the rarified gas densities seen at the surface of the nucleus. However, interparticle cohesive forces present difficulties for this model, and an alternative mechanism for the initiation of reptation and creep may result from the airfall mechanism. The requirements on gas density and other parameters of this alternative make it a more attractive explanation for the observations. The uncertainties and implications are discussed.