Comparing Environmental Risk Regulations in China and the United States.

The relative stringency of risk regulation across countries may have significant implications for public health and environmental outcomes, as well as for economic and trade impacts. In this study, we build on prior literature-which has often employed qualitative case studies, and has often focused on comparing the United States and Europe-by using a quantitative evidential reasoning approach to compare the relative stringency of federal/central level written rules for 45 randomly selected environmental risks in the United States and China. We find that, on average, in this sample of 45 environmental risks, the written rules for environmental risk regulation were more stringent in the United States than in China. Within this sample, we find that relative stringency was selective, leaning in both directions, as the United States and China each regulated some risks more stringently than the other; for example, the US written rules were more stringent for risks of toxic chemicals and most air pollutants, whereas China's written rules were more stringent for risks in agriculture. We also observe nuanced differences in relative regulatory stringency within sectors and risks; even where one country regulated one risk more stringently, the other country may regulate certain aspects of that risk more stringently. We comment on possible explanations for the patterns we observe. Our methods and findings may contribute to better understanding of comparative risk regulation across the United States and China, and worldwide. We also recognize that in addition to the written rules studied here, countries may also vary in their implementation.

Learning to Manage the Multirisk World.

Risk assessment, perception, and management tend to focus on one risk at a time. But we live in a multirisk world. This essay in honor of the 40th anniversary of the Society for Risk Analysis (SRA) and the journal Risk Analysis suggests that we can-and have already begun to-strengthen risk analysis and policy outcomes by moving from a focus on the single to the multiple-multiple stressors, multiple impacts, and multiple decisions. This evolution can improve our abilities to assess actual risks, to confront and weigh risk-risk trade-offs and innovate risk-superior moves, and to build learning into adaptive regulation that adjusts over time. Recognizing the multirisk reality can help us understand complex systems, foresee unintended consequences, design better policy solutions, and learn to improve.

The Value of Information in Decision-Analytic Modeling for Malaria Vector Control in East Africa.

Decision analysis tools and mathematical modeling are increasingly emphasized in malaria control programs worldwide to improve resource allocation and address ongoing challenges with sustainability. However, such tools require substantial scientific evidence, which is costly to acquire. The value of information (VOI) has been proposed as a metric for gauging the value of reduced model uncertainty. We apply this concept to an evidenced-based Malaria Decision Analysis Support Tool (MDAST) designed for application in East Africa. In developing MDAST, substantial gaps in the scientific evidence base were identified regarding insecticide resistance in malaria vector control and the effectiveness of alternative mosquito control approaches, including larviciding. We identify four entomological parameters in the model (two for insecticide resistance and two for larviciding) that involve high levels of uncertainty and to which outputs in MDAST are sensitive. We estimate and compare a VOI for combinations of these parameters in evaluating three policy alternatives relative to a status quo policy. We find having perfect information on the uncertain parameters could improve program net benefits by up to 5-21%, with the highest VOI associated with jointly eliminating uncertainty about reproductive speed of malaria-transmitting mosquitoes and initial efficacy of larviciding at reducing the emergence of new adult mosquitoes. Future research on parameter uncertainty in decision analysis of malaria control policy should investigate the VOI with respect to other aspects of malaria transmission (such as antimalarial resistance), the costs of reducing uncertainty in these parameters, and the extent to which imperfect information about these parameters can improve payoffs.

Initial experience of minimally invasive mesh explantation for inguinodynia.

BACKGROUND: Chronic pain after minimally invasive inguinal hernia repair with mesh can have debilitating effects on quality of life (QOL), limiting daily activities and ability to work. Many medical and surgical options for treatment have been proposed, however there is no consensus on the role of mesh explantation in the management of these patients. METHODS: We performed a retrospective review of all patients who underwent groin mesh removal by robotic or laparoscopic approach from July 2012 to July 2023 at our institution. Patients were interviewed post-operatively to determine their overall pain scores and QOL was assessed using the Carolinas Comfort Scale (CCS) Questionnaire. Patient characteristics, operative times, pre-operative imaging techniques and analgesia use was also recorded. RESULTS: Twenty-two patients underwent groin mesh removal for chronic pain, including 12 robotic and 10 laparoscopic operations. The mean pre-operative pain score in all patients was 7.6/10 compared to 4.0/10 post-operatively. The mean post-operative CCS score was 24, indicating moderate discomfort. Four patients demonstrated CCS scores <11 indicating no discomfort and no patients demonstrated CCS scores >90, indicating severe debilitating discomfort. The majority of patients had a reduction or total cessation of analgesia intake post-operatively. CONCLUSION: Both laparoscopic and robotic mesh explantation for treatment of chronic pain post-inguinal hernia repair is safe and effective in achieving a reduction in pain and reducing the need for long-term analgesia.

Mediastinal Nontuberculous Mycobacterial Infection in Children: A Multidisciplinary Approach.

BACKGROUND: Mediastinal infections due to nontuberculous mycobacteria remain an exceedingly rare entity. Most cases in the published literature do not include pediatric patients. Due to their clinical infrequency, poor response to antimicrobial therapy and often precarious anatomical location, the optimal management of these lesions can be challenging. METHODS: Retrospective medical record review of 4 pediatric cases of mediastinal nontuberculous mycobacteria infection was undertaken. Each child presented with nonspecific respiratory symptoms, including significant acute airway obstruction and required a range of investigations to confirm the diagnosis. Nonresponsiveness to conservative measures and antimycobacterial therapy ultimately resulted in surgical intervention to obtain clinical improvement. RESULTS: All 4 children had extensive evaluation and multidisciplinary involvement in otolaryngology, respiratory medicine, pediatric surgery, infectious diseases and cardiothoracic surgery. They all eventually had their disease debulked via thoracotomy in addition to prolonged antimycobacterial therapy, with successful clinical outcomes. CONCLUSIONS: Mediastinal nontuberculous mycobacteria infections in the pediatric population are rare and diagnostically challenging. A high clinical suspicion should be maintained, and multidisciplinary input sought. Targeted surgery with adjuvant medical therapy can reduce disease burden with minimal long-term morbidity.

The Impact of Homelessness, Substance Use, and Mental Illness on Surgical Inpatient Outcomes in Australia.

This study investigated inpatient surgical outcomes for people experiencing homelessness (PEH) in Australia. Retrospective administrative health data of emergency surgical admissions from a single center over five years, 2015 to 2020, was included. Independent associations between factors and outcomes were analyzed with binary logistic and log-linear regression. Of 11 229 admissions, 2% were experiencing homelessness. People experiencing homelessness were on average younger (49 vs 56 years), more likely to be males than females (77% vs 61%), suffer mental illness (10% vs 2%), and substance use disorders (54% vs 10%). People experiencing homelessness were not more likely to suffer surgical complications. However, male sex, older age, mental illness, and substance use were risk factors for poor surgical outcomes. Homelessness predicted greater odds of discharge against medical advice (4.3 times) and longer length of stay (1.25 times). These results highlighted the need for health interventions simultaneously addressing physical, mental health, and substance use issues in the care of PEH.

The impact of acute surgical unit rostering on National Emergency Access Targets during the COVID-19 pandemic: a single hospital experience.

BACKGROUND: Surgical departments have been dramatically impacted by the novel coronavirus 19 (COVID-19) pandemic, with the cancellation of elective cases and changes to the provision of emergency surgical care. The aim of this study was to determine whether structural changes made within our facility's surgical department during COVID-19 altered National Emergency Access Target (NEAT) times and impacted on patient outcomes. METHODS: Emergency surgical cases over a 4-month time period were retrospectively collected and statistically analysed, divided into pre- and mid-COVID-19 pandemic. RESULTS: Baseline characteristics between the groups were comparable. There was a significant increase in consultant presence in theatre in the COVID group. There were also statistically significant reductions in NEAT times at each timepoint, although these did not meet national guidelines. There was no change in emergency surgical workload, complication rate or mortality rates within 30 days. CONCLUSION: Any significant change to services requires a coordinated hospital-wide approach, not just from a single department, and clinicians must continue to be wary of benchmarked times as the overall feasibility and safety of NEAT times has also been highlighted again.

Social science research to inform solar geoengineering.

What are the benefits and drawbacks, and for whom?.

Damage control laparotomy in a paediatric trauma patient in a regional hospital.

INTRODUCTION: Trauma is a major cause of death in children (Brown et al., 2001). It has far-reaching impacts on a child's development and function, and is a major contributing factor to disability in the young. Pediatric patients in trauma demonstrate different clinical signs and have different resuscitation requirements, often masking symptoms and compensating well before rapidly deteriorating. CASE PRESENTATION: The authors present a case of a 13-year-old patient with major trauma receiving surgical management in an adult regional hospital. The patient was involved in a high-speed head on motorcar collision. This report emphasizes the importance of early mobilisation of a trauma team and appropriate surgical stabilisation of a child in an adult regional centre without access to specialised pediatric surgeons. DISCUSSION: Approximately 600 individuals aged 19 or less are fatally injured in Australia each year. Management of pediatric trauma requires early mobilization of a trauma team, to ensure high levels of expertise are available. However, managing these patients with specialized pediatric surgery teams is not always possible. As such, peripheral hospitals need to have trained general surgeons who can manage the deteriorating pediatric patient. CONCLUSION: All peripheral hospitals with access to emergency operating should have general surgeons willing and able to manage pediatric trauma, with the confidence for a low threshold for laparotomy.

Using decision analysis to improve malaria control policy making.

Malaria and other vector-borne diseases represent a significant and growing burden in many tropical countries. Successfully addressing these threats will require policies that expand access to and use of existing control methods, such as insecticide-treated bed nets (ITNs) and artemesinin combination therapies (ACTs) for malaria, while weighing the costs and benefits of alternative approaches over time. This paper argues that decision analysis provides a valuable framework for formulating such policies and combating the emergence and re-emergence of malaria and other diseases. We outline five challenges that policy makers and practitioners face in the struggle against malaria, and demonstrate how decision analysis can help to address and overcome these challenges. A prototype decision analysis framework for malaria control in Tanzania is presented, highlighting the key components that a decision support tool should include. Developing and applying such a framework can promote stronger and more effective linkages between research and policy, ultimately helping to reduce the burden of malaria and other vector-borne diseases.

Hormesis, hotspots and emissions trading.

Instrument choice--the comparison of technology standards, performance standards, taxes and tradable permits--has been a major topic in environmental law and environmental economics. Most analyses assume that emissions and health effects are positively and linearly related. If they are not, this complicates the instrument choice analysis. This article analyses the effects of a nonlinear dose-response function on instrument choice. In particular, it examines the effects of hormesis (high-dose harm but low-dose benefit) on the choice between fixed performance standards and tradable emissions permits. First, the article distinguishes the effects of hormesis from the effects of local emissions. Hormesis is an attribute of the dose-response or exposure-response relationship. Hotspots are an attribute of the emissions-exposure relationship. Some pollutants may be hormetic and cause local emissions-exposure effects; others may be hormetic without causing local emissions-exposure effects. It is only the local exposure effects of emissions that pose a problem for emissions trading. Secondly, the article shows that the conditions under which emissions trading would perform less well or even perversely under hormesis, depend on how stringent a level of protection is set. Only when the regulatory standard is set at the nadir of the hormetic curve would emissions trading be seriously perverse (assuming other restrictive conditions as well), and such a standard is unlikely. Moreover, the benefits of the overall programme may justify the risk of small perverse effects around this nadir. Thirdly, the article argues that hotspots can be of concern for two distinct reasons, harmfulness and fairness. Lastly, the paper argues that the solution to these problems may not be to abandon market-based incentive instruments and their cost-effectiveness gains, but to improve them further by moving from emissions trading and emissions taxes to risk trading and risk taxes. In short, the article argues that hormesis does not pose a general obstacle to emissions trading or emissions taxes, but that in those cases where hormesis does pose such a problem, a shift toward risk trading or risk taxes would be the superior route.

The impact of DaTscan on the diagnosis and management of movement disorders: A retrospective study.

BACKGROUND: The diagnosis of Parkinson's disease remains a challenge in patients who have abnormal symptoms or show a lack of response to medication. The imaging technique, DaTscan, can be used to visualize dopamine degeneration in the nigro-striatum, which is associated with Parkinsonian Syndrome. We examined the use of the DaTscan in diagnosis, confidence in diagnosis, and clinical management. METHODS: Physicians of 125 patients were contacted to fill out a brief survey about changes in diagnosis, confidence of diagnosis, and clinical management after assessment with the DaTscan. RESULTS: There was an overall increase in confidence of diagnosis with the results of the DaTscan. Physicians also stated that the DaTscan impacted their diagnosis in 68% of the patients, as well as an impact in the clinical management of 58% of the patients. CONCLUSION: The DaTsan can be used as a tool to help diagnose Parkinsonian Syndrome in patients with unclear symptoms.

Assessment of suspected breast cancer by MRI: a prospective clinical trial using a combined kinetic and morphologic analysis.

OBJECTIVE: The objective of our study was to assess the incremental value of contrast-enhanced MRI in the diagnosis and treatment planning using both a three-time point kinetic and morphologic analysis in addition to mammography and sonography in patients thought to have early-stage breast cancer. SUBJECTS AND METHODS: Contrast-enhanced bilateral breast MRI was performed prospectively on 65 patients with highly suspicious imaging findings (BI-RADS category 4 or 5). All enrolled patients were believed to be candidates for breast conservation on the basis of clinical examination, mammography, and sonography. The primary index lesion's characteristics, size, and extent were assessed. Also, additional lesions detected by MRI that could represent potential malignancies in both the ipsilateral and contralateral breast were evaluated. Morphologic assessment and kinetic analysis were performed on each lesion using dedicated postprocessing and display software. The patients were reevaluated as to whether they were still candidates for breast-conservation therapy after the MRI examination and subsequent biopsies. RESULTS: There were 46 patients (71%) whose primary breast lesion (detected by mammography, sonography, or both) was found to be malignant (39 invasive breast cancers, five intraductal cancers, and two lymphomas). For the primary index lesions, the sensitivity for MRI was 100% (44/44) for predicting a breast malignancy and the specificity was 73.7% (14/19) for predicting benign lesions. MRI detected an additional 37 lesions, of which 23 were cancerous, beyond those suspected on mammography or sonography. One or more additional ipsilateral breast cancers were detected in 32% (14/44) of breast cancer patients and contralateral breast cancers in 9% (4/44) of the breast cancer patients. MRI also resulted in an incremental recommendation of mastectomy in 18% (8/44) of the pathologically confirmed breast cancer patients. MRI resulted in additional biopsy of only 14 benign lesions, six of which were shown to be atypical ductal hyperplasia. CONCLUSION: When added to the standard evaluation of clinical examination, mammography, and sonography in patients thought to have early-stage breast cancer, contrast-enhanced MRI using both a kinetic and morphologic analysis will often result in changes in recommended patient management and better treatment planning and will result in no significant increase in biopsies of benign lesions. In addition, there is a significant detection rate of occult contralateral breast cancers.

Precautionary regulation in Europe and the United States: a quantitative comparison.

Much attention has been addressed to the question of whether Europe or the United States adopts a more precautionary stance to the regulation of potential environmental, health, and safety risks. Some commentators suggest that Europe is more risk-averse and precautionary, whereas the United States is seen as more risk-taking and optimistic about the prospects for new technology. Others suggest that the United States is more precautionary because its regulatory process is more legalistic and adversarial, while Europe is more lax and corporatist in its regulations. The flip-flop hypothesis claims that the United States was more precautionary than Europe in the 1970s and early 1980s, and that Europe has become more precautionary since then. We examine the levels and trends in regulation of environmental, health, and safety risks since 1970. Unlike previous research, which has studied only a small set of prominent cases selected nonrandomly, we develop a comprehensive list of almost 3,000 risks and code the relative stringency of regulation in Europe and the United States for each of 100 risks randomly selected from that list for each year from 1970 through 2004. Our results suggest that: (a) averaging over risks, there is no significant difference in relative precaution over the period, (b) weakly consistent with the flip-flop hypothesis, there is some evidence of a modest shift toward greater relative precaution of European regulation since about 1990, although (c) there is a diversity of trends across risks, of which the most common is no change in relative precaution (including cases where Europe and the United States are equally precautionary and where Europe or the United States has been consistently more precautionary). The overall finding is of a mixed and diverse pattern of relative transatlantic precaution over the period.