Lawmakers' use of scientific evidence can be improved

Core to the goal of scientific exploration is the opportunity to guide future decision-making. Yet, elected officials often miss opportunities to use science in their policymaking. This work reports on an experiment with the US Congress—evaluating the effects of a randomized, dual-population (i.e., researchers and congressional offices) outreach model for supporting legislative use of research evidence regarding child and family policy issues. In this experiment, we found that congressional offices randomized to the intervention reported greater value of research for understanding issues than the control group following implementation. More research use was also observed in legislation introduced by the intervention group. Further, we found that researchers randomized to the intervention advanced their own policy knowledge and engagement as well as reported benefits for their research following implementation.

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Effect of Yoga on Performance and Physical Fitness in Cricket Bowlers

International Journal of Yoga Therapy ◽

10.17761/2021-d-20-00060 ◽

2021 ◽

Author(s):

Sumedh S. Vaidya ◽

Bela Agarwal ◽

Yuvraj Singh ◽

Rajani Mullerpatan

Keyword(s):

Physical Fitness ◽

Scientific Evidence ◽

Intervention Group ◽

Control Group ◽

Yoga Intervention ◽

Yoga Group ◽

Cricket Bowling ◽

Speed Accuracy ◽

Cardiorespiratory Endurance ◽

Male Cricket

Abstract Cricket-bowling performance is known to be influenced by speed of ball release and accuracy. Currently, training sessions typically involve fielding-specific drills and conditioning exercises. Scientific evidence for inclusion of a comprehensive yoga intervention in daily training and exercise sessions remains unexplored. The present study explored the effect of yoga on bowling performance and physical fitness in cricket bowlers. Sports fitness testing and training were conducted among 60 non-elite recreational-club male cricket players aged 13–25 years. Cricket-bowling speed was e valuated using a speed radar gun, accuracy with a test developed by Portus et al., cardiorespiratory endurance using the yo-yo intermittent recovery test, lower-extremity and trunk strength using a back-leg dynamometer, upper-limb power using a medicine ball–throw test, power using a vertical-jump test, and flexibility using a sit-and-reach test. In addition to bowling practice, the yoga intervention group (n = 30) performed pranayama and standing and prone asana, whereas the control group (n = 30) practiced conventional conditioning exercises, for 45 minutes/day, three times a week, for 12 weeks. Improvement in bowling speed, accuracy, cardiorespiratory endurance, muscle strength, and flexibility were comparable between the two groups. Statistically significant improvements in baseline scores in bowling speed, accuracy, cardiorespiratory endurance, muscle flexibility, strength, and power were comparable between the two groups of non-elite male cricket players. Bowling speed improved by 6.52% in the yoga group and by 5.18% in the control group. Bowling accuracy improved by 35.40% in the yoga group and by 31.29% in the control group. Additional research on long-duration intervention in elite players may help to establish the role of yoga in conventional cricket-bowling training.

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Reconsidering symbolic use: a situational model of the use of research evidence in polarised legislative hearings

Evidence & Policy A Journal of Research Debate and Practice ◽

10.1332/174426418x15378681033440 ◽

2019 ◽

Vol 15 (4) ◽

pp. 525-541

Author(s):

Robert Asen ◽

Whitney Gent

Keyword(s):

Decision Making ◽

Research Evidence ◽

Rhetorical Analysis ◽

Research Use ◽

Situational Model ◽

The Us ◽

Modes Of Interaction ◽

The Relationship ◽

Scholarly Attention ◽

Use Of Research

Participating in the growing scholarly attention to the roles of rhetoric and argumentation in policymaking, we examine how the use of research evidence operates in explicitly argumentative legislative hearings characterised by partisanship and polarisation. Conducting a rhetorical analysis of three legislative hearings in the US state of Wisconsin, we discovered that partisanship and polarisation did not influence argument and the use of research evidence uniformly. Instead, legislators and committee witnesses employed a range of uses for research evidence. To understand this usage, we have developed a framework that foregrounds situations of research use. These situations consist of conditions of polarisation (visibility, bipartisan leadership, familiarity, and controversy), modes of interaction (participation, cooperation and (dis)qualification), and conceptions of research use (necessity, relevance, and sufficiency). This situational model recognises that symbolic use provides the foundation for the use of research evidence in legislative settings. This model also reconfigures the relationship between research evidence and decision making.

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Revisit the Effectiveness of Educational Kinesiology on Stress and Anxiety Amelioration in Kindergarteners With Special Needs: A Nonrandomized Trial

10.21203/rs.3.rs-407301/v1 ◽

2021 ◽

Author(s):

Pui Lun Alan TAI ◽

Kwok Wai Way LAU

Keyword(s):

Clinical Trial ◽

Special Needs ◽

Scientific Evidence ◽

Intervention Group ◽

Control Group ◽

Clinical Trial Registry ◽

Open Label ◽

Post Intervention ◽

Educational Kinesiology ◽

Registration Number

Abstract Although educational kinesiology is a popular intervention aims to improve brain functioning via physical movements, it lacks supporting scientific evidence. This study explores the effect of educational kinesiology on the changes in stress and anxiety markers in kindergarteners with special needs using psychometrics and biological measures. This open label non-randomized clinical trial was registered retrospectively in the Chinese Clinical Trial Registry (registration number: ChiCTR2000036305, url: http://www.chictr.org.cn/showproj.aspx?proj=58067, registration date: 22/08/2020). Thirty-seven kindergarteners with special needs (3.5-6.5 years old) were assigned to either the intervention group, which received one-hour educational kinesiology intervention weekly for a total of 10 weeks, or the wait-list control group. Scores of Parent-rated Preschool Anxiety Scale (PAS-TC), salivary cortisol and oxytocin levels were obtained pre- and post-intervention. After controlling baseline, the changes in oxytocin levels remained significantly different between groups (F1,35 = 5.590, p = 0.020, eta2 = 0.145), but not in cortisol levels (F1,35 = 0.364, p = 0.550, eta2 = 0.01). PAS-TC showed significant improvement in anxiety levels after the intervention in the intervention group (X2 = 4.367, p = 0.037, φ = 0.344, p = 0.037). Findings from both subjective and objective measures indicate a plausible anti-stress and anxiety effect in kindergarteners with special needs.

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Ultrasound-guided access to the axillary vein for implantation of cardiac implantable electronic devices: A systematic review and meta-analysis

The Journal of Vascular Access ◽

10.1177/11297298211054621 ◽

2021 ◽

pp. 112972982110546

Author(s):

Sonia D’Arrigo ◽

Francesco Perna ◽

Maria Giuseppina Annetta ◽

Mauro Pittiruti

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Statistical Significance ◽

Intervention Group ◽

Late Complications ◽

Control Group ◽

Complication Rates ◽

Axillary Vein ◽

Cardiac Implantable Electronic Devices ◽

The Us

The aims of our systematic review were to quantify the expected rate of procedural success, early and late complications during CIED implantation using US-guided puncture of the axillary vein and to perform a meta-analysis of those studies that compared the US technique (intervention) versus conventional techniques (control) in terms of complication rates. MEDLINE, ISI Web of Science, and EMBASE were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. Thirteen studies were included a total of 2073 patients. The overall success of US-guided venipuncture for CIED implantation was 96.8%. As regards early complications, pneumothorax occurred in 0.19%, arterial puncture in 0.63%, and severe hematoma/bleeding requiring intervention in 1.1%. No cases of hemothorax, brachial plexus, or phrenic nerve injury were reported. As regards late complications, the incidence of pocket infection, venous thromboembolism, and leads dislodgement was respectively 0.4%, 0.8%, and 1.2%. In the meta-analysis (five studies), the intervention group (US-guided venipuncture) had a trend versus a lower likelihood of having a pneumothorax (0.19% vs 0.75%, p = 0.21), pocket hematoma (0.8% vs 1.7%, p = 0.32), infection (0.28% vs 1.05%, p = 0.29) than the control group, but this did not reach statistical significance. The overall QOE was low or very low. In conclusions we found that the US-guided axillary venipuncture for CIEDs implantation was associated with a low incidence of early and late complications and a steep learning curve.

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Revisit the Effectiveness of Educational Kinesiology on Stress and Anxiety Amelioration in Kindergarteners With Special Needs Using Biological Measures

Frontiers in Psychiatry ◽

10.3389/fpsyt.2021.773659 ◽

2021 ◽

Vol 12 ◽

Author(s):

Alan Pui-Lun Tai ◽

Way Kwok-Wai Lau

Keyword(s):

Special Needs ◽

Scientific Evidence ◽

Intervention Group ◽

Small Samples ◽

Control Group ◽

Intervention Programme ◽

Post Intervention ◽

Brain Functioning ◽

Educational Kinesiology ◽

Quasi Experimental

Background: Educational kinesiology is a popular intervention that aims to improve brain functioning via physical movements. Yet, it lacks supporting scientific evidence and is regarded as pseudoscience. Given the popularity of educational kinesiology in school settings, it is important to revisit its effectiveness through scientific research. Previous studies that evaluated the effectiveness of educational kinesiology relied mainly on subjective measures, in which subjective bias is inevitable. Cortisol and oxytocin levels in saliva have been reported to be reliable stress and anxiety markers that provide unbiased objective data. This study explores the effect of educational kinesiology on the changes in salivary cortisol and oxytocin levels in kindergarteners with special needs.Methods: A quasi-experimental design was adopted in this study. Thirty-seven kindergarteners (3.5–6.5 years old) who were either diagnosed with one type of special needs or referred by school principals due to the requirement of special supports at school were assigned to either the intervention group, which received 1-h educational kinesiology intervention weekly for a total of 10 weeks, or the wait-list control group. Saliva samples were collected at baseline and after the completion of intervention programme for the measurement of cortisol and oxytocin levels. Scores of Parent-rated Preschool Anxiety Scale (PAS-TC) were also collected at pre- and post-intervention. Because of the small samples, non-parametric tests such as Mann-Whitney U test, Quade test, and Fisher's exact tests were used in this study where appropriate.Results: After controlled for the effect at baseline, gender and types of special needs, the changes in oxytocin levels were significantly higher in the intervention group compared with control [F(1, 35) = 4.747, p = 0.036, eta2 = 0.119], whereas no significant between-group difference in changes of cortisol levels was observed [F(1, 35) = 0.306, p = 0.584, eta2 = 0.009]. Results from PAS-TC showed significant improvement in anxiety levels after the intervention in the intervention group (p = 0.048, ϕ = 0.344, p = 0.037).Conclusions: Our findings suggest a plausible anti-anxiety effect of educational kinesiology in kindergarteners with special needs by elevating the oxytocin levels. Future studies are warranted to further confirm our findings with a larger sample.

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Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study

Journal of Medical Internet Research ◽

10.2196/17968 ◽

2020 ◽

Vol 22 (5) ◽

pp. e17968 ◽

Cited By ~ 1

Author(s):

Ronald W Gimbel ◽

Lior M Rennert ◽

Paul Crawford ◽

Jeanette R Little ◽

Khoa Truong ◽

...

Keyword(s):

Mobile Health ◽

Intervention Group ◽

Patient Activation ◽

Density Lipoprotein ◽

Self Management ◽

Control Group ◽

Health Care Environment ◽

Waist Size ◽

The Us ◽

Hba1c Control

Background Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. Objective The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. Methods A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. Results The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12). Conclusions Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. Trial Registration ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037 International Registered Report Identifier (IRRID) RR2-10.2196/resprot.6993

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Utility of perfusion imaging in acute stroke treatment: a systematic review and meta-analysis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012751 ◽

2016 ◽

Vol 9 (10) ◽

pp. 1012-1016 ◽

Cited By ~ 12

Author(s):

Won Hyung A Ryu ◽

Michael B Avery ◽

Navjit Dharampal ◽

Isabel E Allen ◽

Steven W Hetts

Keyword(s):

Systematic Review ◽

Acute Stroke ◽

Perfusion Imaging ◽

Meta Analysis ◽

Scientific Evidence ◽

Intervention Group ◽

Cochrane Library ◽

Control Group ◽

Eligibility Criteria ◽

Stroke Treatment

BackgroundVariability in imaging protocols and techniques has resulted in a lack of consensus regarding the incorporation of perfusion imaging into stroke triage and treatment. The objective of our study was to evaluate the available scientific evidence regarding the utility of perfusion imaging in determining treatment eligibility in patients with acute stroke and in predicting their clinical outcome.MethodsWe performed a systematic review of the literature using PubMed, Web of Science, and Cochrane Library focusing on themes of medical imaging, stroke, treatment, and outcome (CRD42016037817). We included randomized controlled trials, cohort studies, and case-controlled studies published from 2011 to 2016. Two independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies.ResultsOur literature search yielded 13 studies that met our inclusion criteria. In total, 994 patients were treated with the aid of perfusion imaging compared with 1819 patients treated with standard care. In the intervention group 51.1% of patients had a favorable outcome at 3 months compared with 45.6% of patients in the control group (p=0.06). Subgroup analysis of studies that used multimodal therapy (IV tissue plasminogen activator, endovascular thrombectomy) showed a significant benefit of perfusion imaging (OR 1.89, 95% CI 1.43 to 2.51, p<0.01).ConclusionsPerfusion imaging may represent a complementary tool to standard radiographic assessment in enhancing patient selection for reperfusion therapy, with a subset of patients having up to 1.9 times the odds of achieving independent functional status at 3 months. This is particularly important as patients selected based on perfusion status often included individuals who did not meet the current treatment eligibility criteria.

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Randomized Controlled Trial of Point-of-Care Ultrasound Education for the Recognition of Tension Pneumothorax by Paramedics in Prehospital Simulation

Prehospital and Disaster Medicine ◽

10.1017/s1049023x20001399 ◽

2020 ◽

pp. 1-5

Author(s):

Paul A. Khalil ◽

Andrew Merelman ◽

John Riccio ◽

Jodi Peterson ◽

Ryan Shelton ◽

...

Keyword(s):

Point Of Care ◽

Controlled Trial ◽

Correct Diagnosis ◽

Intervention Group ◽

Tension Pneumothorax ◽

Control Group ◽

Point Of Care Ultrasound ◽

Randomized Controlled ◽

The Us ◽

Us Intervention

Abstract Objective: The primary goal of this study was to determine if ultrasound (US) use after brief point-of-care ultrasound (POCUS) training on cardiac and lung exams would result in more paramedics correctly identifying a tension pneumothorax (TPTX) during a simulation scenario. Methods: A randomized controlled, simulation-based trial of POCUS lung exam education investigating the ability of paramedics to correctly diagnose TPTX was performed. The US intervention group received a 30-minute cardiac and lung POCUS lecture followed by hands-on US training. The control group did not receive any POCUS training. Both groups participated in two scenarios: right unilateral TPTX and undifferentiated shock (no TPTX). In both scenarios, the patient continued to be hypoxemic after verified intubation with pulse oximetry of 86%-88% and hypotensive with a blood pressure of 70/50. Sirens were played at 65 decibels to mimic prehospital transport conditions. A simulation educator stated aloud the time diagnoses were made and procedures performed, which were recorded by the study investigator. Paramedics completed a pre-survey and post-survey. Results: Thirty paramedics were randomized to the control group; 30 paramedics were randomized to the US intervention group. Most paramedics had not received prior US training, had not previously performed a POCUS exam, and were uncomfortable with POCUS. Point-of-care US use was significantly higher in the US intervention group for both simulation cases (P <.001). A higher percentage of paramedics in the US intervention group arrived at the correct diagnosis (77%) for the TPTX case as compared to the control group (57%), although this difference was not significantly different (P = 0.1). There was no difference in the correct diagnosis between the control and US intervention groups for the undifferentiated shock case. On the post-survey, more paramedics in the US intervention group were comfortable with POCUS for evaluation of the lung and comfortable decompressing TPTX using POCUS (P <.001). Paramedics reported POCUS was within their scope of practice. Conclusions: Despite being novice POCUS users, the paramedics were more likely to correctly diagnose TPTX during simulation after a brief POCUS educational intervention. However, this difference was not statistically significant. Paramedics were comfortable using POCUS and felt its use improved their TPTX diagnostic skills.

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Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study (Preprint)

10.2196/preprints.17968 ◽

2020 ◽

Author(s):

Ronald W Gimbel ◽

Lior M Rennert ◽

Paul Crawford ◽

Jeanette R Little ◽

Khoa Truong ◽

...

Keyword(s):

Mobile Health ◽

Intervention Group ◽

Patient Activation ◽

Density Lipoprotein ◽

Self Management ◽

Control Group ◽

Health Care Environment ◽

Waist Size ◽

The Us

BACKGROUND Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. OBJECTIVE The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. METHODS A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. RESULTS The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12). CONCLUSIONS Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. CLINICALTRIAL ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037 INTERNATIONAL REGISTERED REPORT RR2-10.2196/resprot.6993

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Effects of the US Food and Drug Administration Boxed Warning of Erythropoietin-Stimulating Agents on Utilization and Adverse Outcome

Journal of Clinical Oncology ◽

10.1200/jco.2017.72.6273 ◽

2017 ◽

Vol 35 (17) ◽

pp. 1945-1951 ◽

Cited By ~ 12

Author(s):

John Bian ◽

Brian Chen ◽

Dawn L. Hershman ◽

Norman Marks ◽

LeAnn Norris ◽

...

Keyword(s):

Drug Administration ◽

Food And Drug Administration ◽

Intervention Group ◽

Boxed Warning ◽

Control Group ◽

Probability Models ◽

Serious Adverse Events ◽

The Us ◽

Linear Probability ◽

Erythropoietin Stimulating Agents

Purpose In March 2007, a US Food and Drug Administration boxed warning was issued for erythropoietin-stimulating agents (ESAs) regarding serious adverse events, such as venous thromboembolism (VTE). We evaluated the US Food and Drug Administration’s boxed warning of ESAs used to treat chemotherapy-induced anemia because evidence on the effectiveness of boxed warnings remains inconclusive. Patients and Methods Using 2004 to 2009 SEER-Medicare data, we exploited a natural experiment to examine the effects of ESA boxed warnings on utilization and risk of VTE. The intervention group included Medicare fee-for-services patients diagnosed with colorectal, breast, or lung cancers targeted by this warning and undergoing chemotherapy; the control group included patients with myelodysplastic syndromes not targeted by this warning. The period from January 2004 to September 2006 was used as the prewarning period; the period from April 2007 to September 2009 was used as the postwarning period. The two binary dependent variables included ESA use and hospitalized VTE. Linear probability models with a difference-in-differences specification were used for estimation. Results Our sample consisted of 45,319 unique patients between 2004 and 2009. The trends in ESA use remained similar between the intervention and control groups before the warning, but started declining sharply in the intervention group only after the warning. The trends in hospitalized VTE were relatively stable. Regressions showed that the ESA boxed warning was associated with a 20.2-percentage-point reduction ( P < .001) in the likelihood of ESAs being used to treat cancers targeted by the warning, but not significantly associated with the likelihood of hospitalized VTE. Conclusion Our study showed that the warning was effective in reducing ESA utilization. Future studies should examine other regulatory drug safety actions, such as the Risk Evaluation and Mitigation Strategy initiative, whose effectiveness remains unknown.

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