Louisiana's “Medically Futile” Unborn Child List: Ethical Lessons at the Post-Dobbs Intersection of Reproductive and Disability Justice

Ableist attitudes and structures are increasingly recognized across all sectors of health care delivery. After Dobbs, novel questions arose in the United States concerning how to protect reproductive autonomy while avoiding discrimination against and devaluation of disabled persons. In this essay, we examine the Louisiana Department of Health's emergency declaration, “List of Conditions That Shall Deem an Unborn Child ‘Medically Futile,’” issued August 1, 2022. We raise a number of medical, ethical, and public health concerns that lead us to argue that the declaration should be rescinded. Analysis of this ethically objectionable declaration provides valuable lessons about how to uphold both reproductive and disability justice in a post-Dobbs landscape.     

Hazard Ratio Estimation in Small Samples

When comparing survival times between groups in the setting of proportional hazards, the Cox model is typically used for estimation and inference, the latter based on large sample considerations. Mehrotra and Roth introduced a generalized log-rank (GLR) method for better statistical efficiency in estimating relative risk in small samples. In this article, we propose a refined GLR (RGLR) statistic by eliminating an unnecessary approximation in the development of the original GLR approach, and provide further insights into the performance of GLR and RGLR statistics. We also extend RGLR to allow for tied event times. We show across a variety of simulated scenarios that RGLR provides a smaller bias than commonly used Cox model, parametric models and GLR in small samples (up to 40 subjects per group), and has notably better efficiency relative to Cox and parametric models in terms of mean squared error. The RGLR method also consistently delivers adequate confidence interval coverage and Type I error control, while parametric methods and the Cox model tend to under-perform on that front in small samples. We further show that while the performance of the parametric model can be significantly influenced by misspecification of the true underlying survival distribution, the RGLR approach provides a consistently low bias and high relative efficiency. We apply all competing methods to data from two clinical trials. Supplementary materials for this article are available online.     

Do pain management websites foster self-management support for people with persistent pain? A scoping review

ObjectivesTo evaluate if the contents of pain management websites include the current best practice self-management support strategies for people with persistent pain, are cultural tailored and to determine the website quality.MethodsWebsites were searched from three major search engines (Google, Bing, and Yahoo). Websites providing information on self-management strategies and websites that were freely available to the public were included. The website contents were evaluated using a 14-item self-management support (SMS-14) checklist. Website quality was assessed using the Health On the Net code (HONcode) certification.ResultsOf the twenty-seven websites evaluated, the websites scored a median of nine items (range 1–13) from the SMS-14 checklist. The websites LivePlanBe, ACI Pain Management Network and MyJointPain top-scored (13/14) from the SMS-14 checklist. One website (ACI Pain Management Network) provided culturally tailored information and HONcode certification was present in six websites.ConclusionsThe review identified 27 contemporary pain management websites that could be used for self-management skills training.Practice ImplicationsClinicians could refer people with persistent pain to top ranked websites - LivePlanBe, ACI Pain Management Network, and MyJointPain for enabling self-management skills, with the caveats that most websites lacked cultural tailoring, and have limited or no evidence of clinical efficacy.     

Investigation of a New Couples Intervention for Individuals With Brain Injury: A Randomized Controlled Trial

Objectives

This study aimed to (1) examine the efficacy of a treatment to enhance a couple’s relationship after brain injury particularly in relationship satisfaction and communication; and (2) determine couples’ satisfaction with this type of intervention.

Flagging clinical adverse experiences: reducing false discoveries without materially compromising power for detecting true signals

Comparative analyses of safety/tolerability data from a typical phase III randomized clinical trial generate multiple p-values associated with adverse experiences (AEs) across several body systems. A common approach is to 'flag' any AE with a p-value less than or equal to 0.05, ignoring the multiplicity problem. Despite the fact that this approach can result in excessive false discoveries (false positives), many researchers avoid a multiplicity adjustment to curtail the risk of missing true safety signals. We propose a new flagging mechanism that significantly lowers the false discovery rate (FDR) without materially compromising the power for detecting true signals, relative to the common no-adjustment approach. Our simple two-step procedure is an enhancement of the Mehrotra-Heyse-Tukey approach that leverages the natural grouping of AEs by body systems. We use simulations to show that, on the basis of FDR and power, our procedure is an attractive alternative to the following: (i) the no-adjustment approach; (ii) a one-step FDR approach that ignores the grouping of AEs by body systems; and (iii) a recently proposed two-step FDR approach for much larger-scale settings such as genome-wide association studies. We use three clinical trial examples for illustration.