A rare feat of bipartisan cooperation came to fruition on 22 June 2016 when President Barack Obama signed the Frank R. Lautenberg Chemical Safety for the 21st Century Act (HR 2576).Early indicators suggest the new law will more effectively protect people—including vulnerable populations such as children and pregnant women—than the old law it replaces. But stakeholders are watching closely to see if the changes really do live up to their promise.TSCA was passed in 1976 with the intent of giving the EPA broad powers to protect the public and the environment from potentially dangerous industrial chemicals in U.S. commerce.In passing TSCA, Congress attempted to create a regulatory system for evaluating the safety of industrial chemicals and for restricting uses when necessary to safeguard public health. Empowered by the law, EPA officials could theoretically compel companies to provide health and environmental information to fill critical data gaps. Moreover, TSCA gave them the power to regulate the manufacture, processing, distribution, use, and disposal of chemical substances found to present an “unreasonable risk” of injury to health or the environmentBut in practice, TSCA was dysfunctional, prompting calls for reform that began decades ago. At a 2009 meeting of the Commonwealth Club of San Francisco, then–EPA administrator Lisa Jackson captured long-held sentiments by stating, “Not only has TSCA fallen behind the industry it’s supposed to regulate, it’s been proven an inadequate tool for providing the protection against chemical risks that the public rightly expects.”Two years after that meeting, Bill Chameides, then dean of the Duke Nicholas School of the Environment, blogged that under TSCA the EPA had issued regulations to control just nine of the tens of thousands of industrial chemicals in U.S. commerce. As to the rest of the chemicals, he wrote, “Well … they’re out there.”The reasons for TSCA’s failings are numerous and complex. But according to Lynn Bergeson, managing partner in the Washington, DC–based law firm Bergeson & Campbell, a key factor was that the legal hurdles the EPA had to clear before taking action under the law were excessively burdensome.Corrosion Proof Fittings v. EPA—resulted in a seminal 1991 ruling against the EPA by the U.S. Court of Appeals for the Fifth Circuit, which concluded that by proposing to simply ban asbestos, the agency had failed to adequately consider less burdensome ways to reduce the risk of asbestos exposure, such as labeling products that contain it.Consider what happened when the EPA tried to issue a comprehensive ban on asbestos-containing products in 1989.Plaintiffs and others who felt that public exposures to asbestos were negligible hailed the decision.Meanwhile, roughly 62,000 chemicals already in commerce when TSCA was first enacted were for all intents and purposes exempted from the law. Charles Auer, former director of the EPA’s Office of Pollution Prevention and Toxics (OPPT), and now a consultant in Poolesville, Maryland, says that under TSCA companies had to submit available health and environmental data only when filing premanufacture notices for new chemicals. But there was no comparable policy pushing EPA the to review such data for the chemicals that were already in commerce when TSCA was enacted. “Therefore,” Auer says, “the existing chemicals were essentially grandfathered into TSCA.”The only way the EPA could compel companies to generate new data on existing chemicals was by publishing a rule that would make it a requirement. To justify such a rule, however, the EPA first had to show that the chemicals targeted for testing could potentially present unreasonable health and environmental risks, based on the agency’s review of the existing data. But in many cases, there simply weren’t enough existing data to make that determination, putting the agency in a catch-22: wanting new data without the means to force industry to provide it, according to current OPPT director Wendy Cleland-Hamnett.With TSCA wallowing in dysfunction, states and the marketplace stepped in to fill the regulatory void. That led to a complex patchwork of laws and voluntary programs that companies had difficulty navigating, says Mike Walls, vice president for regulatory and technical affairs at the American Chemistry Council (ACC), an industry trade group in Washington, DC.Martha Marrapese, a partner with Washington, DC, regulatory law firm Keller and Heckman, concurs. She says, “It was very hard for companies to address ten different [state] laws if they were trying to market a product in fifty states.”According to Walls, industry frustration eventually reached the point that the ACC and its member companies began to acknowledge that TSCA reforms were urgently needed. That change in mindset, Denison adds, enabled negotiation with environmental groups, which was reflected in the first bipartisan legislation aimed at modernizing the law. Called the Chemical Safety Improvement Act,Although it was widely seen as flawed,Some of the most important changes in the Lautenberg Act affect three core sections of the law. Section 4, which covers testing, authorizes the EPA to require companies to develop adequate test data. Section 5, which covers manufacturer notification requirements, stipulates that companies submit premanufacture notices at least 90 days prior to manufacturing, importing, or using new chemicals. It also mandates that the EPA review and make affirmative safety findings as a condition for market entry. Section 6, which covers risk evaluation and regulation, allows the EPA to restrict or ban the production, importation, or use of substances should any of those activities present unreasonable risks of health or environmental injury. It also establishes a new prioritization process and mandated review of all existing chemicals, a new safety standard that is not based on costs, and other provisions.The law specifically defines “unreasonable risk,” so that it 1) emphasizes health protection without having to consider the cost–benefit ratio of regulation, 2) focuses on whether and how chemicals are currently used, as determined by the EPA, and 3) explicitly considers and addresses the risk to subpopulations identified by the EPA as potentially exposed or susceptible.Risks above that benchmark are typically deemed unacceptable by the EPA and by state health agencies.Importantly, Marrapese says, the new law removes impediments to the EPA’s authority over existing chemicals. The EPA no longer has to demonstrate the potential for unreasonable risk from an existing chemical before it can require new data by rule making ; the agency can simply order companies to generate whatever health, environmental, or exposure data it deems necessary, according to Mark Duval, a principal with Beveridge & Diamond, a Washington, DC–based law firm.The law also mandates that the EPA determine how many of the 84,000 chemicals currently on the TSCA inventoryOver time, the EPA will split the active chemicals into two categories: a high-priority category for those that may present an unreasonable risk and a low-priority category for those that are deemed not to.Auer says shortcomings under Section 4 were particularly evident during the early 1990s, after the Organisation for Economic Co-operation and Development (OECD), of which the United States is a member, set out to compile a screening information data set for high production volume (HPV) chemicals—those that are manufactured or imported at volumes in excess of 1 million pounds per year.“Companies voluntarily committed to satisfying [screening information data set] requirements, and in so doing they uncovered lots of data from industry that hadn’t been previously released,” Auer says. “But then the OECD changed direction, industry support flagged, and at the end of the day, the voluntary program never fully solved EPA’s issues with inadequate test data.”According to Walls, HPV chemicals used in the United States number roughly 3,000, and the HPV Challenge Program uncovered at least a few screening-level data for roughly 2,300 of them. In most cases, he says, those data supply basic information that the EPA can use to make additional decisions—“they’re not full-blown risk assessments,” he explains, “but enough to give the agency an idea if it needs to conduct a deeper dive.”The new reforms, according to Auer, allow the EPA to order tiered tests for existing chemicals, starting with screening-level hazard and exposure data, and then, if warranted by screening-level findings, moving on to higher-tier tests for end points such as neurotoxicity. “I’m optimistic that through these changes, EPA can crack the test data problem and get the information it needs to conduct prioritization assessments and risk evaluations under Section 6,” Auer says. “I see this as a package that offers great promise.”Per the updated law, the EPA is required to evaluate at least 10 high-priority chemicals within six months of enactment; within three years the agency should be evaluating at least 20 chemicals at any given time, with up to three years allocated to the evaluation of any single chemical. What’s more, the costs of those evaluations (and other tasks associated with administering the new law) will be paid in part by fees levied on industry. According to Cleland-Hamnett, the act allows the EPA to collect fees amounting to 25% of the cost of performing activities under Sections 4, 5, and 6.The first 10 chemicals slated for evaluation, Cleland-Hamnett says, will be drawn from the TSCA Work Plan for Chemical Assessments, which was initially developed by the EPA in 2012 and updated in 2014.N-methyl-2-pyrrolidone in paint strippers.The EPA has already completed evaluations of certain uses for about half a dozen of these chemicals and found significant risk from several uses, Denison says. Consistent with the new emphasis on risk reduction over balancing costs and benefits from regulation, the requirement that the EPA must select the “least burdensome” regulatory alternative—which proved insurmountable in the case of asbestos 25 years ago—has been stricken from TSCA. And that, Denison says, should make it easier for the agency to proceed with regulations slated to be proposed later this year, including restrictions on trichloroethylene in cleaning products, methylene chloride in bathtub refinishers, and And what about that patchwork of laws that states put into place under TSCA? Federal preemption of state laws under the Lautenberg Act proved to be the thorniest issue to negotiate, say sources interviewed for this story. Some stakeholders were concerned that the reformed law could preempt stringent standards that were set by the states when TSCA proved unworkable. Washington State, for instance, banned flame-retardant chemicals that have been shown to disrupt thyroid hormones.After debating preemption for three years, lawmakers agreed to grandfather in Proposition 65 and any other state actions taken before 22 April 2016. At the same time, the law prohibits states from enforcing statutes or laws that duplicate TSCA information requirements under Section 4, and likewise it does not allow them to ban or restrict chemical uses that the EPA has determined do not pose unreasonable risks. Unless they obtain a waiver, states therefore would be precluded from, for instance, setting more stringent standards for chemicals than those imposed by any upcoming EPA regulation.“If EPA were to propose something less than a total ban on those chemicals, then by TSCA’s authority, the states themselves would not be allowed to,” says Daniel Rosenberg, senior attorney with the Natural Resources Defense Council. “However, states might try to ban the chemicals by invoking some other state law. So you can expect legal challenges, both from the states and also from the chemical industry.” In Rosenberg’s view, the quality of the EPA’s risk evaluations will determine if the law represents a new benefit for public health. Still, he adds, “The new TSCA is a much better law.”Others also have praised the new TSCA. The ACC’s Walls says, “It creates a federal structure that enhances public safety while preserving an ability for companies to innovate and compete in a global market.” Denison concurs, saying, “The reformed TSCA offers significant improvements on just about every count.”Cleland-Hamnett, whose office bears responsibility for implementing the TSCA reforms, agrees. “It’s a major accomplishment in terms of updating an environmental law that was not working well before, and a huge opportunity to protect human health and the environment,” she says. “I’m honored to have the ability to work on it.”Federal Register notice from August 26, the EPA will take nominations and comments through October 11.In August 2016 the EPA issued a call for nominations to serve on a new expert panel—the Science Advisory Committee on Chemicals—charged with providing guidance on upcoming TSCA risk assessments. The committee will consist of 14 members who meet three to four times per year. According to a


House GOP members Rep. Mark Meadows (R-NC) and Rep. Raúl Labrador (R-ID) recently made alarming and misleading statements about American emergency departments’ role in U.S. healthcare. In March of this year, while speaking with CNN’s New Day host Alisyn Camerota, Mr. Meadows stated:“The goal is to allow access to all. There’s a federal law right now that if you show up at a hospital, you get coverage, Alisyn. And so, it’s a false narrative to suggest we have people who can’t go in and get coverage. It’s a federal law.”1After passing the House GOP American Health Care Act (AHCA) last Thursday, which would allow individual states to seek waivers to eliminate essential health benefits, including emergency department visits, this narrative was reiterated by Mr. Labrador at a town hall meeting in Southern Idaho. The statement was met with loud boos by constituents, and a video of the event has been widely shared on social media. In response, Labrador stated on Saturday:“In the five-second clip that the media is focusing on, I was trying to explain that all hospitals are required by law to treat patients in need to [sic] emergency care regardless of their ability to pay and that the Republican plan does not change that.”2It is vital that all Americans, including Mr. Meadows and Mr. Labrador understand the details of the law they are referencing, including why the law certainly does not provide healthcare access or “coverage.” The law, called the Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 in response to “patient dumping,” the practice of hospitals refusing to treat people with medical emergencies because of their inability to pay or insufficient insurance. “Patient dumping” also applies to early and inappropriate hospital discharge due to high anticipated treatment costs.Firstly, EMTALA only applies to “participating hospitals,” those that accept Medicare and Medicaid payments. Combined payments for Medicare and Medicaid in 2015 totaled $1.19 trillion, making up 45% of national health expenditures, which total $3.2 trillion. This makes not participating in EMTALA impractical for nearly all hospitals.Next, contrary to the misconception assumed by many, including Mr. Meadows and Labrador, EMTALA does not mandate treatment of non-emergent conditions. EMTALA only mandates that providers provide a “medical screening exam” including blood tests, imaging, and consultation with specialists as necessary to decide whether an emergency medical condition (EMC) does or does not exist. The U.S. government defines an EMC as “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.”While Mr. Meadows and Mr. Labrador are correct in saying that under EMTALA, Americans presenting to their local emergency departments are eligible to receive care, the law does not mandate care be provided under three caveats:patients will only receive care if they have an EMC;EMTALA contains no requirement for physicians and hospitals to provide uncompensated care or stabilizing treatment for patients with non-emergency conditions; anduninsured or underinsured patients are still responsible for the costs of care and will be personally billed for all services. There is no “coverage” at all, only mandated emergency care for which the patient still must pay (or go bankrupt).EMTALA was passed in 1986 without any funding whatsoever, so there is no “insurance” component to the law that our congressmen refer to as “coverage.” EMTALA is considered by many to be an “unfunded mandate.”4Further, stating that access to care in emergency departments implies access to care in general ignores the fact that board-certified emergency physicians, like myself, are trained as experts in emergencies, not routine primary care. We spent years becoming experts in the diagnosis and treatment of life-threatening conditions such as cardiac arrest, respiratory failure, acute kidney failure, shock states (very low blood pressure), emergent child delivery, poisonings, acute heart failure, stroke, neonatal emergencies, blunt and penetrating injury, and much more.We do not specialize in routine health maintenance including disease prevention or surveillance, and management of chronic diseases like high blood pressure, diabetes, asthma, heart disease, cancer, obesity, arthritis, chronic pain, psychiatric disorders, and a variety of other “pre-existing conditions” affecting millions. If the AHCA is signed into law in its current form, millions of Americans will once again be uninsured, preventing them from accessing primary care.6So, yes, Reps. Mark Meadows and Raúl Labrador are correct when they say that federal law requires everyone to be seen in America’s emergency departments. But what they neglect to mention is that treatment of non-emergent conditions is not and will not be required, and uninsured patients will receive bills for all services rendered. This will return us to the pre-Obamacare era when Americans were sicker and routinely delayed seeking care early for minor problems. With no access to primary care, more Americans will once again need to file for bankruptcy due to lack of health insurance and mounting medical bills. And, in the long run, care for these people will be more expensive to society, when we treat only the emergency when the disease is far advanced.


The diagnostic yield in open access endoscopy has been evaluated which generally support the effectiveness and efficiency of open access endoscopy. With a few exceptions, diagnostic yield studies have not been performed in open access endoscopy for more specific conditions. Therefore, we conducted a study to determine the efficiency of open access endoscopy in the detection of microscopic colitis as compared to traditional referral via a gastroenterologist.A retrospective search of the pathology database at the University of Missouri for specimens from a local open access endoscopy center was conducted via SNOMED code using the terms: “microscopic”, “lymphocytic”, “collagenous”, “spirochetosis”, “focal active colitis”, “melanosis coli” and “histopathologic” in the diagnosis line for the time period between January 1, 2004 and May 25, 2006. Specimens and colonoscopy reports were reviewed by a single pathologist.Of 266 consecutive patients with chronic diarrhea and normal colonoscopies, the number of patients with microscopic disease are as follows: Lymphocytic colitis , collagenous colitis , focal active colitis , and spirochetosis .The diagnostic yield of microscopic colitis in this study of an open access endoscopy center does not differ significantly from that seen in major medical centers. In terms of diagnostic yield, open access endoscopy appears to be as effective in diagnosing microscopic colitis. Open access endoscopy (OAE) is defined as the performance of endoscopic procedures requested by referring physicians without a prior clinic consultation . OAE is Studies addressing the diagnostic yield of endoscopy in OAE for all causes are available; among which cancers, adenomas, and inflammatory bowel disease are separately designated , 5-7. AtMicroscopic colitis is a treatable illness causing chronic non-bloody diarrhea. Usually, mild or no abnormalities are seen at colonoscopy. The incidence of microscopic colitis varies from 4.2-10% per year per 100 000 people . BiopsieIn this study, we determined the diagnostic yield of biopsies from patients at an open-access endoscopy center in Columbia, Missouri. The information from this study will be useful in the ongoing discussion on the effectiveness of open access endoscopy.A retrospective study at the University of Missouri-Columbia was performed following approval of the Investigation Review Board. A search of the surgical pathology database was conducted via SNOMED code for specimens, in which the words “microscopic”, “lymphocytic”, “collagenous”, “spirochetosis”, “focal active colitis”, “melanosis coli” and “no histopatholologic” are found in the diagnosis. These keywords represent the scope of diagnoses expected to be given to patients that would have received a colonoscopy for chronic diarrhea with normal colonoscopic findings.Specimens from 497 consecutive patients at a single private practice, open-access endoscopy center in Columbia, Missouri are obtained and colonoscopy reports are reviewed for the period January 1, 2004 and May 25, 2006. Specimens are accessioned and the tissues and slides are prepared at the University of Missouri. All cases are reviewed and diagnosed by a single pathologist specializing in gastrointestinal pathology.From this group of specimens, 231 patients were excluded for not meeting the study criteria. Exclusion criteria include patients whose colonoscopy report lists a previous history of inflammatory bowel disease (n = 29), patients with abnormal colonoscopic findings consistent with colitis, such as ulcerations or erythema (n = 35), patients who do not have chronic diarrhea listed as the indication for their colonoscopy (n = 162), and patients whose endoscopy report is missing from our records (n = 5). We chose not to exclude patients with diverticulosis, polyps, or other endoscopic findings unlikely to cause chronic diarrhea.The diagnosis of lymphocytic colitis is as defined by Lazenby et al . CollageA total of 266 cases met the clinical criteria for microscopic colitis . A total of 67 males and 199 females fulfilled the study criteria. The age distribution, mean, and median ages for the total sum of patients and for patients among diagnostic categories are found in Microscopic colitis is being recognized increasingly as a cause of non-bloody diarrhea in older adults. Our study showed an improved diagnostic yield of microscopic colitis in patients as compared to those published previously worldwide. Given that this difference is an increase rather than a decrease in the diagnostic yield of OAE, there is no evidence to support the supposition that open access colonoscopy is less effective or efficient than colonoscopy performed after specialist referral, as is the practice among many major medical centers and where all previous studies of diagnostic yield in microscopic colitis have occurred.In some specialty medical centers such as open endoscopy centers, both pathologist and laboratory are employed by and also frequently located in the center. This raises the question of a potential conflict of interest, as endoscopists may have greater incentive to increase their biopsy rates. Because the pathologist reviewing slides and our laboratory are separate from the OAE center, our study is inadequate to assess the influence of this potential conflict of interest that may exist in such a situation.It is noteworthy that the most recent studies of microscopic colitis have the highest diagnostic yield . A signiWhether this increase reflected a true increase in incidence, an increase in the awareness of the disease by pathologists, or an increase in the number of patients being evaluated by colonoscopy for chronic diarrhea is not known , 22. An


When discussing results medical research articles often tear substantive and statistical  contributions apart, just as if both were independent. Consequently, reasoning on bias tends to be vague, unclear and superficial. This can lead to over-generalized, too narrow and misleading conclusions, especially for causal research questions.To get the best possible conclusion, substantive and statistical expertise have to be integrated on the basis of reasonable assumptions. While statistics should raise questions on the mechanisms that have presumably created the data, substantive knowledge should answer them. Building on the related principle of Bayesian thinking, we make seven specific and four general proposals on writing a discussion section.conditional conclusions other researchers may, according to their knowledge and beliefs, follow a particular conclusion or, based on other conditions, arrive at another one. This could foster both an improved debate and a better understanding of the mechanisms behind the data and should therefore enable researchers to better address bias in future studies.Misinterpretation could be reduced if authors explicitly discussed what can be concluded under which assumptions. Informed on the resulting  After a research article has presented the substantive background, the methods and the results, the discussion section assesses the validity of results and draws conclusions by interpreting them. The discussion puts the results into a broader context and reflects their implications for theoretical  and practical  purposes. As such, the discussion contains an article’s last words the reader is left with.how to deal with the complex bias issue, and how to get to and report conclusions.Common recommendations for the discussion section include general proposals for writing  and struConsequently, suggestions on writing a discussion often remain vague by hardly addressing the role of the assumptions that have (often implicitly) been made when designing a study, analyzing the data and interpreting the results. Such assumptions involve mechanisms that have created the data and are related to sampling, measurement and treatment assignment  and, as a consequence, the bias this may produce , 6. TheyIn this article, we argue that the conjunction of substantive and statistical  knowledge in the verbal integration of results and beliefs on mechanisms can be greatly improved in  research papers. We illustrate this through the personal roles that a statistician (i.e. methods expert) and a substantive researcher should take. Doing so, we neither claim that usually just two people write a discussion, nor that one person lacks the knowledge of the other, nor that there were truly no researchers that have both kinds of expertise. As a metaphor, the division of these two roles into two persons describes the necessary integration of knowledge via the mode of a dialogue. Verbally, it addresses the finding of increased specialization of different study contributors in biomedical research. This has teared apart the two processes of statistical compilation of results and their verbal integration . When thThe article addresses both  researchers educated in basic statistics and research methods and statisticians who cooperate with them. Throughout the paper we exemplify our arguments with the finding of an association in a cross-tabulation between a binary X (factor) and a binary Y (outcome): those who are exposed to or treated with X have a statistically significantly elevated risk for Y as compared to the non-exposed or not (or otherwise) treated (for instance via the chi-squared independence test or logistic regression). Findings like this are frequent and raise the question which more profound conclusion is valid under what assumptions. Until some decades ago, statistics has largely avoided the related topic of causality and instead limited itself on describing observed distributions (here a two-by-two table between D = depression and LC = lung cancer) with well-fitting models.D causes LC (e.g. because smoking might constitute “self-medication” of depression symptoms)LC causes D D and LC cause each other (e.g. because the arguments in both a. and b. apply)D and LC are the causal consequence of the same factor(s) D and LC only share measurement error .We illustrate our arguments with the concrete example of the association found between the factor depression (D) and the outcome lung cancer (LC) . Yet verreflect on mechanisms in order to find the right answer. Besides, we do not consider research on the D-LC relation apart from the finding of association . For instance, hospitalization might be influenced by both D and LC, and thus sampling from hospitals might introduce a false association or change an association’s sign; particularly D and LC may appear to be negatively associated although the association is positive in the general population . In contrast to conventional wisdom, measurement error does not always bias association and effect estimates downwards , 6. It dh errors .Note that what is in line with common standards of “good” measurement  might anyway produce large bias. This applies to estimates of prevalence, association and effect. The reason is that while indices of measurement are one-dimensional, bias depends on two parameters (sensitivity and specificity) , 22. Mor1 and Z2 because this “blocks” all paths that otherwise lead backwards from D to LC. Note that fully eliminating bias due to confounding also requires that the confounders have been collected without measurement error [Assessment of bias due to confounding variables (roughly speaking: common causes of factor and outcome) requires assumptions on the entire system of variables that affect both factor and outcome. For example, D and LC might share several causes such as stressful life events or socioeconomic status. If these influence D and LC with the same effect direction, this leads to overestimation, otherwise (different effect directions) the causal effect is underestimated. In the medical field, many unfavorable conditions may be positively related. If this holds true for all common factors of D and LC, upward bias can be assumed. However, not all confounders have to be taken into account. Within the framework of “causal graphs”, the “backdoor criterion”  providesnt error , 6, 23. Whereas the statistician should pinpoint to the mathematical insight of the backdoor criterion, its application requires profound substantive input and literature review. Of course, there are numerous relevant factors in the medical field. Hence, one should practically focus on those with the highest prevalence (a very seldom factor can hardly cause large bias) and large assumed effects on both X and Y.If knowledge on any of the three kinds of bias is poor or very uncertain, researchers should admit that this adds uncertainty in a conclusion: systematic error on top of random error. In the Bayesian framework, quantitative bias analysis formalizes this through the result of larger variance in an estimate. Technically, this additional variance is introduced via the variances of distributions assigned to “bias parameters”; for instance a misclassification probability (e.g. classifying a true depression case as non-case) or the prevalence of a binary confounder and its effects on X and Y. Of course, bias analysis also changes point estimates (hopefully reducing bias considerably). Note that conventional frequentist analysis, as regarded from the Bayesian perspective, assumes that all bias parameters were zero with a probability of one , 6, 23. If the substantive investigator understands the processes of selection, measurement and confounding only poorly, such strict analysis numerically reveals that little to nothing is known on the effect of X on Y, no matter how large an observed association and a sample  may be , 6, 23).Propose a specific study design that requires less and weaker assumptions for a conclusionUsually articles end with statements that only go little further than the always true but never informative statement “more research is needed”. Moreover, larger samples and better measurements are frequently proposed. If an association has been found, a RCT or other interventional study is usually proposed to investigate causality. In our example, this recommendation disregards that: (1) onset of D might have a different effect on LC risk than an intervention against D , (2) the effects of onset and intervention concern different populations (those without vs. those with depression), (3) an intervention effect depends on the mode of intervention , and (4)(8)Don’t mistake the absence of evidence as evidence for absenceuninformative. In this case, the wording “there is no evidence for an association” is adequate because it does not claim that there is no association.A common pitfall is to consider the lack of evidence for the alternative hypothesis (e.g. association between D and LC) as evidence for the null hypothesis (no association). In fact, such inference requires an a-priori calculated sample-size to ensure that the type-two error probability does not exceed a pre-specified limit . Otherwise, the type-two error is unknown and in practice often large. This may put a “false negative result” into the scientific public that turns out to be “unreplicable” – what would be falsely interpreted as part of the “replication crisis”. Such results are neither positive nor negative but (9)Strictly distinguish between discussing pre-specified hypotheses and newly proposed hypotheses from post-hoc analysesp-hacking”, [Frequently, it remains unclear which hypotheses have been a-priori specified and which have been brought up only after some data analysis. This, of course, is scientific malpractice because it does not enable the readership to assess the random error emerging from explorative data analysis. Accordingly, the variance of results across statistical methods is often misused to filter out the analysis that yields a significant result . Pre-plnew hypotheses created from data exploration. The distinction is profound, since a newly proposed hypothesis just makes a new claim. Suggesting new hypotheses cannot be wrong, this can only be inefficient if many hypotheses turn out to be wrong. Therefore, we suggest proposing only a limited number of new hypotheses that appear promising to stimulate further research and scientific progress. They are to be confirmed or falsified with future studies. A present discussion, however, should yet explicate the testable predictions a new hypothesis entails, and how a future study should be designed to keep bias in related analyses as small as possible.On the other hand, post-hoc analyses can be extremely useful for identifying unexpected phenomena and creating new hypotheses. Verbalization in the discussion section should therefore sharply separate between conclusions from hypothesis testing and Confidence intervals address the problem of reducing results to the dichotomy of significant and non-significant through providing a range of values that are compatible with the data at the given confidence level, usually 95% .p-values are often misinterpreted to be: the probability that the alternative (or null) hypothesis is true [before inspecting the data. In Bayesian statistics (unlike frequentist statistics) a parameter is a random number that expresses prior beliefs via a “prior distribution”. Such a “prior” is combined with the data result to a “posterior distribution”. This integrates both sources of information.This is also addressed by Bayesian statistics that allows calculating what frequentist  is true . Moreove is true , 16. To Note that confidence intervals also can be interpreted from the Bayesian perspective . This assumes that all parameter values were equally likely  before analyzing the data , 6, 20.(10)Do not over-interpret small findings. Statistical significance should not be mis-interpreted as practical significancep-value does not measure strength of association [p-value <.001. A further problem arises if the significance threshold of .05 is weakened post-hoc to allow for “statistical trends” (p between .05 and .10) because a result has “failed to reach significance” .Testing just for a non-zero association can only yield evidence for an association deviating from zero. A better indicator for the true impact of an effect/association for clinical, economic, political, or research purposes is its magnitude. If an association between D and LC after adjusting for age and gender has been discovered, then the knowledge of D has additional value in predicting an elevated LC probability beyond age and gender. However, there may be many other factors that stronger predict LC and thus should receive higher priority in a doctor’s assessment. Besides, if an association is small, it may yet be explained by modest (upward) bias. Especially large samples often yield significant results with little practical value. The ociation . For insIt is usually the statistician’s job to insist not only on removing the attention from pure statistical significance to confidence intervals or even Bayesian interpretation, but also to point out the necessity of a meaningful cutoff for practical significance. The substantive researcher then has to provide this cutoff.(11)Avoid claims that are not statistically well-foundedp = .049), but this association is not significant (e.g. p = .051), when adjusting for “health behavior”. This does not imply that “health behavior” “explains” the association (yet fully). The difference in magnitude of association in both analyses compared here (without and with adjustment on HB) may be very small and the difference in p-values (“borderline significance” after adjustment) likely to emerge from random error. This often applies to larger differences in p as well.Researchers should not draw conclusions that have not been explicitly tested for. For example, one may have found a positive association between D and LC .Investigators, however, might find patterns in their results that they consider worth mentioning for creating hypotheses. In the example above, adding the words “in the sample”, would clarify that they refer just to the difference of two Yet when considering 1) through 7); i.e. carefully reflecting on the mechanisms that have created the data, discussions on statistical results can be very misleading, because the basic statistical methods are mis-interpreted or inadequately worded.Some issues of discussing results not mentioned yet appear to require only substantive reasoning. For instance, Bradford Hill’s consideration on “plausibility” claims that a causal effect is more likely, if it is in line with biological (substantive) knowledge, or if a dose-response relation has been found . HoweverThere are, however, some practical issues that hinder the cooperation we suggest. First, substantive researchers often feel discomfort when urged to make assumptions on the mechanisms behind the data, presumably because they fear to be wrong. Here, the statistician needs to insist: “If you are unable to make any assumptions, you cannot conclude anything!” And: “As a scientist you have to understand the processes that create your data.” See  for pracSecond, statisticians have long been skeptical against causal inference. Still, most of them focus solely on describing observed data with distributional models, probably because estimating causal effects has long been regarded as unfeasible with scientific methods. Training in causality remains rather new, since strict mathematical methods have been developed only in the last decades .The cooperation could be improved if education in both fields focused on the insight that one cannot succeed without the other. Academic education should demonstrate that in-depth conclusions from data unavoidably involve prior beliefs. Such education should say: Data do not “speak for themselves”, because they “speak” only ambiguously and little, since they have been filtered through various biases . The subwhy they share it (or not). If the result is uncertainty, this might motivate them to write their next discussion differently. The proposals made in this article could help shifting scientific debates to where they belong. Rather than arguing on misunderstandings caused by ambiguity in a conclusion’s assumptions one should argue on the assumptions themselves.Readers may take this article as an invitation to read further papers’ discussions differently while evaluating our claims. Rather than sharing a provided conclusion (or not) they could ask themselves whether a discussion enables them to clearly specify


Chronic stress, known to contribute to negative physical and mental health outcomes, is closely associated with broader issues of material hardship, poor neighborhood conditions, residential instability, and inadequate housing conditions. However, few studies have comprehensively explored pathways to stress in a low-income housing environment. A mixed-methods pilot study investigated the concept of energy insecurity by looking at the impacts of weatherization and energy efficiency interventions on low-income households in the South Bronx neighborhood of New York City. In-depth interviews were conducted with 20 low-income heads of household; participants also completed health, housing and budget assessments. Physical deficiencies, economic hardship, and health issues all interacted to directly and indirectly produce living conditions that contribute to chronic stress. Households with higher stress reported more health problems. Poor quality housing led to coping responses that increased expenses, which in turn increased stress around housing and energy affordability. This study provides further support for the connections between both health and the built environment and between low socio-economic status populations and net negative health outcomes. Energy insecurity is an important contributor to chronic stress in low-income households, and isolating pathways to stress where there is potential for interventions is important for future policy and housing-based strategies. Living in pervasive poverty is closely linked to chronic stress for low-income populations ,2,3. On Furthermore, children living under conditions of prolonged adversity and chronic poverty are at greater risk of exposure to hormonal stress response and of experiencing toxic stress, manifested as disruptions of the brain’s architecture and other systems during sensitive developmental periods ,10. ThesIn low-income populations, poor housing quality, residential instability, lack of affordability, and deprived neighborhood conditions represent significant sources of stress ,14,15,16Many low-income householders also struggle with energy insecurity. “an inability to adequately meet household energy needs” . This caUsing both qualitative and quantitative data, this article seeks to advance understanding of the many challenges facing low-income households by identifying the driving forces that may lead to chronic stress in the realms of housing and household energy. Previous research based on the present study examined the impacts of energy efficiency upgrades and showed that improvements in thermal comfort, enhanced health and safety and lower energy expenses were achieved but larger housing issues persisted in spite of benefits . In the The data for this paper are drawn from a mixed-methods pilot study conducted in collaboration with the Association for Energy Affordability (AEA), a community-based weatherization provider. The study investigated the concept of energy insecurity by looking at the impacts of weatherization and energy efficiency interventions on low-income households in the South Bronx neighborhood of New York City . AEA staQualitative interviews were conducted with the head of household to explore experiences with energy insecurity and housing conditions, and their connection to health and economic problems. If there was more than one adult in the home, the reference person for AEA paperwork was considered the head of household. Participants also completed several assessments at baseline, including (a) a health survey to measure household health status and healthcare utilization patterns, the Perceived Stress Scale; (b) a retrospective utility audit to understand energy consumption and expenses; and (c) a budget audit that itemized household expenses including housing, utility, food, transportation, personal, child and medical care, telecommunications, pet, and entertainment expenses.Participants were asked a series of questions pertaining to housing, energy, household economics, health and stress. Questions were derived from validated surveys and scales as described below ,31,32,33Housing: the US Census Bureau American Housing Survey (AHS), including questions on building structure and maintenance, occupancy, and pest infestation.Energy: the Department of Health and Human Services Home Energy Insecurity Scale Survey (HEIS), the Department of Energy S4 Occupant survey.Household Economics: the budget audit estimates each participant’s expenses on a monthly basis, by category. Included are expenditures for housing, utilities, food, transportation, children, personal care, medical expenses, entertainment, pets, and miscellaneous. Since food purchased with Supplemental Nutrition Assistance Program (SNAP) benefits could be considered as not an expense by some participants, all analyses involving food expenses were conducted including and excluding food purchased with SNAP benefits. No significant differences were observed between the two.Health: the asthma survey, based on the NYC Neighborhood Asthma and Allergy Study (NAAS), posed questions related to household members’ asthma and other respiratory conditions as well as disease severity and care management. Questions adapted from the SF-12 health survey  covered Stress: the Perceived Stress Scale (PSS) is the most commonly used measure of perceived stress . It is dThe present analysis explored associations between stress, housing conditions, household expenses, and health that emerged from the quantitative measures and qualitative themes. Quantitative analysis was conducted using SAS to examine associations between higher levels of stress and other survey variables using linear regression and the Wilcoxon Mann-Whitney U-test in the case of non-parametric data. Sensitivity analyses imputing missing data points by various methods determined that models were robust, and statistics given are for the data as originally reported. The research team then conducted a thematic analysis based on qualitative data to further explore issues pertaining to increased stress levels, and to elucidate the associations observed in the quantitative analysis.Perceived Stress. The mean PSS score among participants was 12.5 (SD = 8.61), with the highest score being 27 and the lowest being 0 . This mean score falls within the range reported in several national surveys that utilized the PSS [ the PSS . In our Physical deficiencies contributed directly and indirectly to stress. Lack of thermal comfort caused by poor building conditions was a direct source of stress for participants, who reported being exposed to uncomfortably cold temperatures on a near-daily basis.“My dogs couldn’t sleep, they would shiver... I mean literally, I had to put clothes in there, I gave them the heater, I put the heater for my dogs. And my wife was sleeping in a sweater like this, hoodied up, sweatpants, socks... she can’t stand it and it really affects her. And, it was a rough winter here.”—10011“The front room, that’s why this is out here (pointing to bed in living room) because it’s like I’m not sleeping in there... F***ing cold, I mean it’s freezing. In there, I mean you can probably see your breath in the air. That’s how cold it is in that room alone.”—10010Participants cited problems with poor insulation, damaged or improperly sealed doors and windows, and inadequate heating systems as the main factors impacting their thermal comfort and inadequacies in household energy more broadly. For private homeowners, the physical deficiencies were generally a result of not being able to independently afford home improvements and energy efficiency upgrades, while for renters the issues were a result of improper maintenance and upkeep by landlords.“I would get snow and water (inside my home from) the draft on the door... If the wind would blow one way, we would have snow piling up in the house. I couldn’t get that fixed. I had the front door broken with no lock that you could just push it with a finger for years, because I couldn’t afford a new door... So for a few years I had no security whatsoever for the door.”—10003“When I moved in here, the window in the kitchen, at the fire escape wouldn’t stay open. So you would have to prop it up... that’s messy, because it’s the window. It’s a method of escape and if you can’t keep the window open or to get out, it’s a dead weight window. And that took three months. And that was only because the city came and did that...”—10010Indirectly, these physical deficiencies also led to additional stress associated with problems of home safety and security as noted by homeowners and renters alike:p = 0.02); 50% of participants in the sample reported having used secondary heating equipment to compensate for inadequate thermal conditions. In turn, the use of secondary heating equipment was associated with a significantly higher level of perceived stress (parameter estimate: 0.86 (95% CI: 0.75–0.99), p = 0.03). In association with the use of secondary heating equipment, participants expressed concerns related to physical health and increased energy costs, both of which led to increased stress.Unsurprisingly, living in poorly insulated homes was significantly associated with the use of secondary heating equipment (parameter estimate: 0.09 (95% CI: 0.01–0.70), Interviewer: “Did you ever use your stove or oven to provide heat?”Respondent: “Yes... I only did it one time cause like I was telling her, running that gas is not healthy at all, but it was unbearable so it had to be done.”—10011Secondary heating equipment used to keep homes at an adequate temperature can be potentially dangerous, and includes the use of space heaters, ovens and stoves. Use of these heating sources contributes to harmful exposures and increases the risk of fire and fire-related injury and death ,38,39,40p = 0.006). Participants who used secondary heating equipment had significantly higher average monthly utility bills ($418.60 ± $161.99) compared to those who did not ($200.56 ± $129.99).The use of secondary heating equipment also raises utility bills. A non-parametric test showed that the use of secondary heating equipment was associated with increased monthly utility expenses (“Right now the (utility bill) I just got was not that high, it was two sixty five for one month. And then next month it’s gonna be a little higher, could be more... because my mother uses the electric heater.”—10009The physical deficiencies discussed here had direct links to stress through chronic exposure to cold temperatures in the home. Indirect links included concerns over health and safety of participants and their families, and the need to use secondary heating equipment leading to further concerns about safety, and about higher energy expenses .p = 0.002). A budget audit, detailed in Economic hardship were a second major source of stress within the study population. The “trifecta of insecurity”, as previously described by Hernández  is obserAs confirmed in “I was trying not to default on the mortgage. That was the main thing. The water bill was here, that was there, and you know, it was rough... you know, the anxiety would build. When it comes, the bills show up, and then there’s no money, and school started, and the kids have this, and then, you know, of course, it puts you in an emotional state.”—10002“I’ve gotten a light bill for $1,100 dollars. That’s impossible, I don’t own a store. That is impossible. And who has to suffer and pay it? We did... How you gonna get that when you gotta pay $1,300 dollars rent? You know, we all have budgets, so. Yes it has been rough, as far as when it comes to that light.”—10011“When I do the level billing at the end of the year, there’s always a large amount that I have to pay. So then I always have to tell them, you know, I can’t pay it all. It’s always in the thousands. So even though the level billing is great, because I’m fixed on one thing, but at the end of the year that’s when the stress level comes.”—10003p < 0.001), confirmed by participant interviews. As demonstrated in the results related to physical deficiencies, poor housing conditions often exacerbated high monthly energy expenses.Not only did many participants struggle to pay their monthly rent or mortgage, but also high monthly energy expenses were a critical source of concern. Increases in the frequency of participants worrying about not being able to pay their home energy bills were strongly correlated with increases in perceived stress (parameter estimate: 6.09 (95% CI: 4.43–7.74), p = 0.02).During the in-depth interviews, participants discussed how their health issues, both physical and mental, were sources of stress, particularly among those with a high number of diagnosed ailments, as indicated by a statistically significant association between the number of health problems affecting household members and perceived stress levels (parameter estimate: 2.25 (95% CI: 0.39–4.1), “I have low blood pressure, so with the asthma it’s a problem. Last year one Sunday I was sweeping the leaves. The next day I couldn’t even breathe, I had to go to the doctor. I ended up in the hospital period... So every time I get sick from the asthma it’s a problem, because of the medication issues. I can’t take inhalers.”—10009“When we didn’t have a furnace... they would bundle up. Then her boyfriend loaned us three heaters... you had to do what you had to do. You know?... We had to deal with a lot of colds, my asthma.”—10003“He’s gone through depression because he couldn’t find a job and he felt horrible. And a couple days ago he says, ‘Mom, I feel bad going to school... I’m a man now’... But, so he’s stressed out. And he’s been depressed with this now.”—10003At the same time, the stress associated with poor health status was not only a result of the health issues themselves, but also from the financial strain associated with the healthcare costs.“I was hospitalized in February and so they made a single payment of like 9000 dollars and so there’s an outstanding balance of like sixty something thousand dollars and so sometimes they call me... how am I going to pay? Imagine that quantity.”—10008Interviewer: “Now tell me a little about the anxiety you were describing, like feeling anxious…”Respondent: “Yeah, that’s a lot. Because I don’t know, like when I got injured it was like what’s gonna happen? And then I had the misfortune that the insurance company for compensation has been horrible. They delay my payments for three, four months, and I’ve had to fight. And I couldn’t go to work... the anxiety of you know, when was my next check? I was down to my last payment. After that I didn’t know how I was going to pay.”—10003Additional health issues associated with stress were referenced in the previous section. For example, as noted above, some participants living in poor quality housing resorted to using their stove or oven to provide heat, which resulted in stress from concerns about toxic effects of gas fumes and risk of fire or contending with the discomfort of extreme home temperatures. Poor quality housing also caused concerns about health and safety from lack of security, leading to increased stress.The results of the present study indicate that there is no singular factor responsible for stress among participants, but that a variety of physical deficiencies, economic hardship, and health issues convene to create conditions that can result in chronic stress. Of the three main themes described here, physical deficiencies both contributed directly to stress as well as indirectly to economic and health issues that lead to stress, demonstrating the strong links between housing conditions and stress along direct and indirect routes. Poor housing conditions led to coping strategies  that increased energy expenses and also increased participant’s concerns over health and safety. These factors, in turn, contributed to stress independently and through associations between factors. As such, this article offers a novel assessment of the intersecting links between housing conditions, energy insecurity, economic hardship, health and stress. As exposure to chronic stress leads to increased susceptibility to adverse health events , which iOverall the results point to a “trifecta of insecurity”, where physical, economic, and health issues all contribute to stress among our study participants . PhysicaAs was seen in Frequent worry about being able to pay energy and household bills, concerns over the health and safety of household members, and high numbers of health issues in the household were all sources of stress among study participants. For households with high numbers of health issues, stress was a result of the health issues themselves, as well as worries over the financial costs associated with treatment and care. Participants who were consistently worried about the health and safety of their families, about their ability to pay their bills, and who were also suffering from health problems, were likely to report increased stress.Given the known associations between chronic stress, allostatic load, and negative health outcomes, it is unsurprising that households with higher stress would report more health problems. As stress increases susceptibility to adverse health events , it is mPrevious research has demonstrated that improvements to housing conditions targeting thermal comfort and energy efficiency can improve both the physical and mental health of household members ,43,44,45Another avenue to address stress and health disparities is through housing-based interventions. Property owners investing in their buildings through physical repairs and energy efficiency upgrades can experience a variety of benefits. Investment in building improvements can increase property values and reduce energy expenses . Further2.5, NO2, and nicotine in green homes as compared to control homes [An additional pathway for intervention in housing conditions is through the Department of Housing and Urban Development (HUD). In the past, HUD has worked with researchers such as Dr. James Krieger on the Healthy Homes Program, aimed at removing lead and other potential hazards from the home ,47. Thisol homes , and othThe small sample size and specific location of this pilot study limit the generalizability of results. Moreover, the strength of the quantitative analysis was limited to basic statistical tests rather than more sophisticated methods including multivariable analysis given the limited sample size. In the case of the budget audits, participants’ self-reported expenses; expense data was not validated through receipts or bank statements and in some cases reporting was incomplete or unclear. Accordingly, the qualitative interviews were an integral part of the data analysis and results, as they helped complement the quantitative results, as well as uncover issues that were not evidenced in the quantitative portion of the study. Despite these limitations, the findings were supported by quantitative results, qualitative results, or both, and merit more attention in future studies.This study helps illuminate the links between low-income housing conditions, energy insecurity, and stress. It also provides further support for the connections between health and the built environment and between low SES populations and net negative health outcomes. The aforementioned policies and housing based interventions are viable options for improving housing conditions and reducing stress among low-income households. However, more needs to be done to examine health and socioeconomic status in the housing environment in order to design the most effective interventions.


De Morbis Cutaneis. A Treatise of Diseases Incident to the Skin (1714) and Syphilis. A Practical Dissertation on the Venereal Disease (1717). Turner demonstrates an awareness of the precarious position of both the surgeon and the syphilitic, and devotes significant portions of his text to advising the trainee surgeon on how to manage patients' reticence over disclosure of symptoms, expectations for cure and impudence towards medical authority. In turn, the trainee must manage his own reputation as a moral and medical authority who can treat all distempers, yet without condoning or facilitating the shameful behaviours associated with a sexual disease. Furthermore, shaming plays a key role in enabling Turner to fashion an ideal patient whose successful cure will both respond to and build the surgeon's medical authority and that of the medical field in general.This article offers a historical corollary to the examination of shame in medical practice by considering the negotiation of shame in the treatment of a stigmatised disease at a time in which surgeons themselves occupied a highly ambivalent social position. It will focus on case studies provided by Daniel Turner (1667–1741), prominent surgeon and later member of the College of Physicians, in his textbooks  De Morbis Cutaneis. A Treatise of Diseases Incident to the Skin (1714), was the first book solely dedicated to diseases of the skin;Syphilis. A Practical Dissertation on the Venereal Disease (1717),i In these texts, shaming plays a key role in enabling Turner to fashion an ideal patient whose successful cure will both respond to and build the practitioner's medical authority, and that of professional medicine in general. Historians of emotions hold the eighteenth century as a transitional period for how Western culture experienced, understood and used shame,iiThis article offers a historical perspective to the consideration of shame and medicine by examining the negotiation of shame by a prominent early eighteenth-century surgeon and physician, Daniel Turner 1667–1741). This was a period in which surgeons themselves occupied a highly ambivalent social position and their customers enjoyed greater choice of domestic and market medical care. Physicians and surgeons therefore had to employ a variety of methods to attract and keep customers, and to ensure their compliance. I draw on the case studies and further notes provided in two of Turner's mid-career texts: the first, 667–1741.De Morbis Cutaneis and Syphilis as he was using his past success as a surgeon to make the unusual move to a physician. He styles his prior practice as that of a ‘learned surgeon’, stressing his education in order to distance himself from the more stigmatised elements of that profession , was an extended attack on quack practitioners, and he regularly stressed how his own ‘choice and try'd Remedies' were ‘approv'd by the constant Practice of good Authors, and confirm'd by our own’ (ref. r). He contrasts this against the rhetorical techniques of quacks and the hyperbolically diverse symptoms that they claim for venereal disease:Pox; if you happen to be giddy, heavy or dull, faint or feeble in your Limbs, ‘tis all from the Pox: if the Palms of Hands are hot, ‘tis also from a Pocky Ferment. Nay, if your Urine does but stink of Piss, ‘tis still the Pox. if your Head akes, it is the Publishing medical theories and case notes was a widespread and effective means of self-promotion and soliciting business, although this function also necessitates careful scrutiny of them as evidence of doctor–patient interactions. It is highly probable that Turner embellishes his rate of patient retention and cure in the texts (and we unfortunately do not have any manuscript records from him), which would serve both to increase his professional reputation and to encourage compliance in readers who may themselves be future patients. Turner published ion ref. , p. 304.yrurgica 695, was De Morbis Cutaneis with a list of cited authors; since this does not include page numbers, it functions purely to emphasise his research credentials. As Steven Shapin has demonstrated, social capital fostered by such ‘gentlemanly practices’ was instrumental in establishing individual and collective credibility for the new science (ref. r). Illnesses themselves are pictured cowering before the wisdom of trained physicians, who can confront a chancre with a ‘Caustick [that] will humble its proud Looks and quickly level it’ (ref. v).Turner opens nce ref. , p. xxi.nce ref. , sig.O1rv), and although medical texts were known to have a broader readership, would not necessarily have expected his anonymous patients to read their own case histories in his books. Where he indicts them in the texts as uncooperative or disrespectful, it is not to produce shame in the individuals, but to enhance his own professional image and sense of authority; as Michael Warner has noted, shame was understood as not requiring perception by the victim in order for the shamer to feel power (ref. v). He advises young surgeons treating the pox that ‘what ever Way the Disease has been contracted’, it ‘behoves you’ to treat the patient's illness and leave ‘the Punishment of his Offence to the Checks upon his own Mind, or that Being against whose Mandates his Trespass was committed’ (ref. r). Privately, whether treating the pox or a less stigmatised disorder, Turner uses shaming rhetoric to increase his professional authority over patients and reads their compliance and cure as evidence of an honest contrition that can then be translated through print into a public performance. The widespread embrace of such rhetorical positioning and attacks on competitors, and the increasing power of Augustan physicians in the ‘medical marketplace’, produced a plethora of satirical representations attacking their vanity and shameful inattention to their patients' well-being . For Turner, this equates to a duty to promise no more or less than is medically possible to his patient. Turner includes some cases that did not achieve a perfect remedy, and in one instance insists that he is ‘not ashamed to let the Reader see, how I have been foyled’ in a pair of cases (ref. v). This objection is qualified, however, by his emphasised consultation with other practitioners, which renders the shame of the failure not merely his own—not only did he consult Sergeant-Surgeon Charles Bernard but another ‘Person pretending to a Secret for this Disease’ is also unable to offer an effective remedy (ref. r). Another elderly man comes to him with ‘a Pox of many Years standing’ that has left him with a ‘dripping rotten Penis’ . Turner makes a point of calling in the surgeon William Petty, ‘being willing to have a Witness in what Condition this poor Fellow came out of the Quack's Hands’ before he attempts to treat him (ref. v). More damning is his self-reflection after convincing a female patient to let him excise a red birthmark from over her eyebrow, which proves more difficult than he had anticipated. He then remarks that, ‘Had I apprehended it so deeply rooted, I might not probably have been so very forward in the Undertaking, unless I had been solicited thereto by the Patient’ (ref. v). He attempts to exonerate himself by emphasising that he made sure to do his utmost once he had undertaken the treatment, rather than risking a relapse ‘to the Patient's farther Inconvenience and my own Discredit’ (ref. v). Joan Lane records that such gossip about the personalities, successes and failures of individual practitioners played a significant role in securing them further work and could circulate for several years after treatment (ref. v). The surgeon's ‘bungling Patch-Work’ shows as disgracefully inferior to ‘the Creator's Workmanship’ as ‘the Puckering Work of a silly Child’ against ‘the finest Cambrick’ (ref. v). Turner offers an exhaustive and extremely defensive account of his treatment of a woman with severe burns to the face. He consults with another surgeon, warns the unmarried woman's parents ‘they must take her Face as happen'd’ (ref. v) and afterwards challenges ‘boasting Pretenders [to] undertake the like difficult Task, and leave smoother or handsomer Work behind them’ (ref. r–v). He then records with satisfaction the ‘Scorn and Indignation’ with which she dismisses a ‘young Novice’ and ‘villainous Oculist’ who offer to better his results (ref. v).Healthcare was a highly diverse and competitive field with a limited code of medical ethics prior to ‘the professionalization of medical morality’ from the late eighteenth century ref. , p. 853.ses ref. , sig.D3vedy ref. , sig.D3rhim ref. , sig.P8vnt’ ref. , sig.K3vit’ ref. , sig.K3vent ref. , p. 220.ent ref. , sig.T2vck’ ref. , sig.T2v'd’ ref. , sig.T4vlts ref. , sig.T6vtechnically competent help’ (ref. r-v). Where illness suggested a dishonourable dependence, however, fear and shame could compel sufferers who were not yet physically incapacitated to hide their symptoms, rather than withdraw and lose their place or become reliant on charity . Though Turner diagnoses tinea, the father insists that ‘it was only a little Hurt from the Teeth of his Comb … and he wanted only a Bit of Plaister to heal it’ (ref. v). Turner is insulted by this request, as well as the father's disregard for his professional opinion, stating (presumably in front of the son) that if the father is ‘so very cunning [ie. knowledgeable]’ (ref. v–M1r) he can treat the boy himself. Soon, however, the father must humbly return since, as Turner sneers, ‘notwithstanding all the good Wives Remedies’ that have been employed, the boy's condition has worsened (ref. r). Shame in front of superiors was acknowledged to be more powerful than the equivalent before equals or social inferiors , and Turner echoes this in condemning a female patient's genitals as ‘fittest to suffer on Account of the wanton Use she had made of them’ (ref. v). Turner allowed for transmission in utero, through breast feeding, bed sharing or other close contact, but followed the majority opinion in concluding it ‘a venemous or contagious Distemper, for the most part contracted by impure Coition, or at least some Contact of the Genitals of both Sexes, or some other lewd and filthy Dalliance between each other that way tending’ (ref. v). The standard treatment in this period was salivation provoked by the topical application and/or ingestion of mercury, the side effects of which became as well-known and stigmatised as the bodily signs of the disease itself. This fed an immense market in quack medicines that stressed their discretion and efficiency. Related advertisements for barrenness and impotence treatments available at particular locations show how secrecy could depend upon sufficient affluence to employ a discrete servant . Turner therefore offers reassurance that, although confinement is preferable, ‘some  have gone about their Affairs as usual’ (ref. r). In spite of Turner's threats, several customers in Syphilis leave his care prematurely, and he shames them as responsible for the return of their symptoms. Turner regularly confers with patients but never records their own speech, instead informing the reader of exchanges in retrospect, such as the case of a repentant recalcitrant who, he alleges, ‘was very sorry he had not been govern'd by my former Advice; for he found my Predictions were come to pass, and he could only blame his own Obstinacy and Indiscretion’ (ref. v). In comparison, good patients, ‘much fearing the lurking Snake’ continue with their treatments in spite of improved conditions (ref. v).Turner acknowledges with frustration that many individuals are unable or unwilling to isolate themselves for long periods of mercury treatment. He praises a patient for having ‘strictly conform'd to the Rules prescrib'd, keeping his Chamber the whole time, which very much contributes to the Success of these Cures’, but acknowledges that ‘tis seldom that these People can have such Opportunity’ ref. , sig.L2rons ref. , sig.C7vv). Turner also reflects that ‘Women of the Town’ are at an advantage over ‘modest’ women infected ‘by an unkind or brutish Husband’: the former, operating under a different hermeneutics of suspicion about the body, recognise variations as signs of pox, ‘take the Alarm presently, seek out for Help, and … so soon as possible get rid of it’, whereas modest women mistake their symptoms for natural fluctuations in the body, or other lower-level disorders, and have ‘run into the last Degree of a Pox, before they knew what their Illness was, or look'd out for a proper Remedy’ . Honour could play a further role in diagnosis as physicians read the same symptoms as venereal or not depending on the patient's relationship to stigmatised risk groups: the author of Medicina Flagellata (1721) mocked doctors who read the same symptoms as scurvy in ‘sober discreet’ individuals, and as the pox in those ‘appearing inclined to Wantonness’ (ref. v). Turner reports patients whose symptoms appear venereal, but whom he is satisfied are ‘honest’, such as a man who is diagnosed with a clap by ‘one who call'd himself a Barber-Surgeon’: ‘the poor old Man, in great Anger, goes Home and tells his Wife how he has been abus'd, and she well satisfied of her own and her Husband's Honesty, came along with him to me … I pity'd the old Man’ (ref. v). Conversely, he suggests that a woman who attempts to attribute her pox to wearing the clothing of an infected man to a masquerade, ‘perhaps was also after [the fashion of] the Masque, otherwise than by simply putting on the Habit’, suggesting that she has engaged in the sexual dissolution commonly attributed to these assemblies (ref. r).All medicine was moral in this period, and individuals were held responsible for maintaining the balance in their constitutions. Those who could not avoid disclosing illness or forsaking social responsibilities might attempt to exonerate themselves from culpability by highlighting their good moral character and social contributions, and attributing their illness to external factors ref. , p. 168.ss’ ref. , sig.D1vellata 171 mocked ellata 171 mocked Penis' . Female patients faced the added disadvantage of modesty comprising a key part of virtuous womanhood, with chastity determined by the maintenance of boundaries around the body . He also criticises doctors who ‘are very shy of these Enquiries’ and will not examine or press their patients for fear of insulting and ‘loosing [sic]’ them, especially when they are of a higher social standing than the physician (ref. v).Contending with the modesty and reticence of patients was a constant concern of practice, particularly since so much of diagnosis depended on their disclosure of symptoms and possible causes ref. , p. 89. ody ref. , p. 52. out ref. , p. 205.r). At first, Turner allows the gentleman to determine his access to physical examination (‘with some Difficulty I was admitted to see’), but as the patient fails to improve, Turner develops a ‘Suspicion of the real Cause’, and he asserts his physical authority over the man's sickbed and body: ‘I observ'd his Linnen stained with a Running, which I show'd him; at the same Time taking hold of the Penis, that he had before used very industriously to conceal’ . Turner informs the now ‘weeping’ gentleman that this evidence confirms his professional opinion on the ‘Nature of his Disease’ and renders cure possible (ref. v). Turner's forceful physicality here is readily contrasted against the non-venereal case of a ‘couragious young Gentlewoman’ with a scabby growth on her forehead (ref. r). When he visits her, she tells him that she has similar marks over her body, and he asks to see them: ‘I desir'd she would show me her Elbows, and (if she pleas'd) her Knees … With the First she readily comply'd … [then] she told me the Tops of her Knees were rather worse … and the rest of her Body was perfectly free’ . His concession that she should only show him her knees ‘if she pleas'd’ acknowledges, and may in fact have emphasised the possible immodesty in the act and the woman's embarrassment. After several visits, and the treatment having commenced under Turner and ‘an honest careful [female] Nurse’, Turner is able to view the woman's leg: ‘In turning down her Stockings by the Nurse, I prevail'd with the young Gentlewoman to let me take a View of one of her Knees, which she show'd me’ (ref. v–D1r). That he waits until the nurse has uncovered her leg, rather than asking her to undress specifically, maintains propriety of both patient and physician in this encounter.The hesitation Turner meets in some of his requests for examination, and the varying levels of negotiation he enters into with different patients, are indicative of his management and concessions to shame and power in his interactions with different classes of patients. For example, he treats a ‘very precise and exact Gentleman’ who on first consultation attributes pain and swelling in his genitals to ‘lying cross-legg'd in his Sleep’, denying all possibility of venereal infection ref. , sig.L8rble ref. , sig.L8vead ref. , sig.D2rr). More unusually, he includes aesthetic concerns in his discussion of penile operations. Incisions in the foreskin are accompanied by an ‘inconvenience’ in that some patients ‘are after incommoded by the flagging Lips hanging down like the Thrills under a Cocks Throat’ (ref. v). This may not only cause embarrassment through physical difficulties in urinating or ‘the Use of Women’ but ‘at best being an Eye-sore, puts the Patient sometime after upon complyance with a Circumcision, by which he may be freed from farther Trouble’ although he must then contend with the derogatory (particularly anti-Semitic) associations of circumcision in this period . Turner, assisted by Bernard, operates on a 14-year-old boy with a severely obstructed urethra, cutting into his penis while servants hold him down and his mother watches (ref. v–7r). Turner whispers to Bernard that they should also remove the ‘pendulous Lips’ of the foreskin, at which ‘the Boy over-heard us Talking, and cry'd out in Passion, he would die before we should cut again’ (ref. r). The boy's mother supports his decision, but Turner is concerned not only for the inconvenience this may cause him but also that it might subsequently ‘redound to my Discredit’ (ref. r). He ‘unwillingly’ complies with their desire to leave off cutting (ref. r) and does what he can with bandaging and liniments. The boy offers assurance that he can urinate satisfactorily, but Turner takes a startling glee in recounting that ‘I hear since that is apt to scatter, and (unless he takes Care and has Opportunity) to wet his Cloaths’ (ref. r). As with Turner's other ‘foolish’ former patients, shaming this child in print serves to promote his medical expertise.Turner also speaks of the need to treat patients in a manner mindful of their future exposure to bodily shame. Like many surgeons, he expresses concern about leaving visible scars, especially in the face, ‘where the utmost Diligence is wanted to prevent Deformity’ ref. , sig.T1rDe Morbis Cutaneis, he offers a remedy for haemorrhoids composed of sitting in warm milk and oil of poppies or violets, and adds that ‘for poor People Flannels wrung out of the same, prepar'd in lesser Quantity may suffice’, thus enabling them to access treatment for a fraction of the apothecary's fee (ref. v). In Syphilis, he changes from daily visits to twice-weekly for a long-term patient who can no longer afford the expense and treats another ‘Poor, but honest Woman’ poxed by her husband for free, ‘purely as an Act of Charity’ (ref. r–v). Elsewhere a merchant patient resists salivation, ‘having much Business upon his Hands’ (ref. r–v). In contrast to the elite men whose ‘performative libertinism’ might incorporate a consciously shameless approach to diseases like the poxr–v). Turner does not treat any elite figures in Syphilis, but his comments on such ‘libertines’ are mild; for example, he announces the condom to be ‘the best, if not only Preservative our Libertines have found out at present; and yet, by reason of its blunting the Sensation, I have heard some of them acknowledge, that they had often chose to risque a Clap, rather than engage cum Hastis sic clypeatis [with spears thus sheathed]’ . His emphasis is predominantly on his own wit, rather than castigation.Turner treated patients of all social classes and demonstrates an awareness of possible embarrassment for those too poor to access adequate medical care. In fee ref. , sig.Q3vv). In diagnosis and treatment, Turner privileges the use of forethought and the expense of time initially where it will save it in the long term. This is applicable to both the surgeon and patient, who share the responsibility for ‘verify[ing] not an old Proverb, More Haste, worse Speed’ . The fast treatment might not only prove medically inadequate but also fail to allow sufficient time for the patient to consider the actions that brought him or her to this impasse. Turner admonishes those who do not offer a performative contrition, reproaching a former patient for ‘rather glorying in his Shame, than endeavouring to conceal his Folly’ by showing pieces of his syphilitic bone in a box as a boast to friends (ref. r). The phrase ‘glorying in shame’ originates in Philippians 3:19 and recurs across early-modern texts as a severe condemnation of the abrogation of dominant morality.iii For some patients, such prompts to shame as Turner provided may have satisfied desire for a penitential component of their treatment as important as any medication.Nevertheless, Turner's representation of the libertines as choosing to ‘risque’ their health is echoed across critiques of shamed behaviours. His emphasis on the ‘innocent’ contagion of deluded wives, and so on, also acknowledges, and in some senses exacerbates, the stigmatisation of less innocent contractors ref. , p. 42. Syphilis, Turner warned: ‘although I would have you be their Confidents, I must dissuade [young practitioners] by all Means from being their Companions … [or] you will hereby make your selves mean, be despised of all those of Reputation’ . Turner does not challenge the stigmatisation of pox, but nevertheless castigates patients who attempt to hide their disease and its cause, especially when it puts his own reputation at risk. He berates one patient for ‘his Modesty, or rather Folly, in concealing his Case’, and causes him to beg for discretion: ‘He coloured and presently fell a weeping, conceiving well it would avail him nothing to deny it, but begg'd of me to be careful of his Reputation, which was considerable among his Party, and which I promis'd him that I would’ (ref. v–M1r). Doctor–patient confidentiality was not yet an axiomatic feature of practice, rendering Turner's promise of secrecy necessary (ref. Incognito’ (ref. r), including one woman who insists on remaining masked (ref. v). Such cases also help us to understand why ashamed patients may have remained with Turner despite his castigations, rather than increase their risk of exposure by consulting multiple practitioners.For all practitioners discussing venereal diseases, it was of course in their best interests to limit the patients' stigmatisation, and thus discount possible ‘courtesy stigma’ attaching to themselves.ary ref. , p. 211.r). Recounting this case at its conclusion, Turner's use of ‘modest’ is revealed to be intended ironically. Despite Turner leaving detailed instructions, he says, ‘being perfectly easie, [she] arose daily and went abroad, by which her Dressings felling into Wrinkles, were apt to slip off, and in one Night's Time … by her Negligence, the Parts were growing fast together’ (ref. r). She and her mother are proven to be careless and negligent, and Turner compels her to beg for treatment and to promise chastity:r)I ask'd jestingly, if she was content, provided we took Care to secure a Passage for her Urine, to let the other Part remain as it was; which (to hear what she would say) I told her could not now be parted without a great deal of Pain: She beg'd I would assist her, and divide with as little Pain to her as possible, promising to be more careful as well as chast for the Future. Ref. , sig.R6rIn another venereal case, Turner comprehensively undermines the woman's attempts to maintain modesty as a means of forcing her complete submission to his regime. After scarifying and dressing her severely ulcerated genitals, Turner proposes returning each day to change the dressings. The woman declines, suggesting that she will be more comfortable if her mother performs the task: ‘this modest Creature seeming asham'd to be thus expos'd every Day, now the Danger was past, desir'd I would leave Dressings for her Mother to put on’ ref. , sig.R6rer’ ref. , sig.R6rTurner's assistance is predicated on the woman's performance of shame and contrition, enacted in submission to his medical authority and renunciation of previous sexual immodesty.De Morbis Cutaneis and Syphilis, Turner demonstrates the precarious relationship to shame occupied by everyone involved in early eighteenth-century healthcare. Printed at a transitional point in his career, De Morbis Cutaneis in particular, with its ostentatious display of learned reading, represented Turner's conscious project to prove himself worthy of the membership of the College of Physicians, and physicians deserving of their elevated position in the medical marketplace. His performative humility before the sick body and received medical authority needed to be balanced with the denigration of alternative healthcare perspectives from informal healers that abounded in the period. The physician crafted and managed his own reputation as a moral and medical authority who could treat all distempers. Though this had to include venereal diseases, it could not be seen as condoning or facilitating the shameful behaviours associated with a sexual illness. Turner thus devotes significant portions of his texts to managing patients' reticence over disclosure of symptoms, expectations for cure and impudence towards medical authority. Turner advises trainee surgeons and physicians to treat patients with pox regardless of their stigmatisation, with the understanding that they will instead be subject to self-imposed castigations that can provoke performative shame. The patients' adherence to the doctor's strict regimens can serve as evidence of this contrition and their desire to return to the morally elevated position of ‘good health’. Conversely, resistance to the physician's directions testifies to the patient's lack of interiorised shame and ethical development.In