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Association Between the Use of Antidepressants and the Risk of Type 2 Diabetes: A Large, Population-Based Cohort Study in Japan

OBJECTIVE

This study aimed to reveal the associations between the risk of new-onset type 2 diabetes and the duration of antidepressant use and the antidepressant dose, and between antidepressant use after diabetes onset and clinical outcomes.

RESEARCH DESIGN AND METHODS

In this large-scale retrospective cohort study in Japan, new users of antidepressants (exposure group) and nonusers (nonexposure group), aged 20–79 years, were included between 1 April 2006 and 31 May 2015. Patients with a history of diabetes or receipt of antidiabetes treatment were excluded. Covariates were adjusted by using propensity score matching; the associations were analyzed between risk of new-onset type 2 diabetes and the duration of antidepressant use/dose of antidepressant in the exposure and nonexposure groups by using Cox proportional hazards models. Changes in glycated hemoglobin (HbA1c) level were examined in groups with continuous use, discontinuation, or a reduction in the dose of antidepressants.

RESULTS

Of 90,530 subjects, 45,265 were in both the exposure and the nonexposure group after propensity score matching; 5,225 patients (5.8%) developed diabetes. Antidepressant use was associated with the risk of diabetes onset in a time- and dose-dependent manner. The adjusted hazard ratio was 1.27 (95% CI 1.16–1.39) for short-term low-dose and 3.95 (95% CI 3.31–4.72) for long-term high-dose antidepressant use. HbA1c levels were lower in patients who discontinued or reduced the dose of antidepressants (F[2,49] = 8.17; P < 0.001).

CONCLUSIONS

Long-term antidepressant use increased the risk of type 2 diabetes onset in a time- and dose-dependent manner. Glucose tolerance improved when antidepressants were discontinued or the dose was reduced after diabetes onset.




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Effects of Bariatric Surgery in Early- and Adult-Onset Obesity in the Prospective Controlled Swedish Obese Subjects Study

OBJECTIVE

Bariatric surgery is an effective treatment for obesity, but it is unknown if outcomes differ between adults with early- versus adult-onset obesity. We investigated how obesity status at 20 years of age affects outcomes after bariatric surgery later in life.

RESEARCH DESIGN AND METHODS

The Swedish Obese Subjects study is a prospective matched study performed at 25 surgical departments and 480 primary health care centers. Participants aged 37–60 years with BMI ≥34 kg/m2 (men) or ≥38 kg/m2 (women) were recruited between 1987 and 2001; 2,007 participants received bariatric surgery and 2,040 usual care. Self-reported body weight at 20 years of age was used to stratify patients into subgroups with normal BMI (<25 kg/m2), overweight (BMI 25–29.9 kg/m2), or obesity (BMI ≥30 kg/m2). Body weight, energy intake, and type 2 diabetes status were examined over 10 years, and incidence of cardiovascular and microvascular disease was determined over up to 26 years using data from health registers.

RESULTS

There were small but statistically significant differences in reduction of body weight among the subgroups after bariatric surgery (interaction P = 0.032), with the largest reductions among those with obesity aged 20 years. Bariatric surgery increased type 2 diabetes remission (odds ratios 4.51, 4.90, and 5.58 in subgroups with normal BMI, overweight, or obesity at 20 years of age, respectively; interaction P = 0.951), reduced type 2 diabetes incidence (odds ratios 0.15, 0.13, and 0.15, respectively; interaction P = 0.972), and reduced microvascular complications independent of obesity status at 20 years of age (interaction P = 0.650). The association between bariatric surgery and cardiovascular disease was similar in the subgroups (interaction P = 0.674). Surgical complications were similar in the subgroups.

CONCLUSIONS

The treatment benefits of bariatric surgery in adults are similar regardless of obesity status at 20 years of age.




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Predicting 10-Year Risk of End-Organ Complications of Type 2 Diabetes With and Without Metabolic Surgery: A Machine Learning Approach

OBJECTIVE

To construct and internally validate prediction models to estimate the risk of long-term end-organ complications and mortality in patients with type 2 diabetes and obesity that can be used to inform treatment decisions for patients and practitioners who are considering metabolic surgery.

RESEARCH DESIGN AND METHODS

A total of 2,287 patients with type 2 diabetes who underwent metabolic surgery between 1998 and 2017 in the Cleveland Clinic Health System were propensity-matched 1:5 to 11,435 nonsurgical patients with BMI ≥30 kg/m2 and type 2 diabetes who received usual care with follow-up through December 2018. Multivariable time-to-event regression and random forest machine learning models were built and internally validated using fivefold cross-validation to predict the 10-year risk for four outcomes of interest. The prediction models were programmed to construct user-friendly web-based and smartphone applications of Individualized Diabetes Complications (IDC) Risk Scores for clinical use.

RESULTS

The prediction tools demonstrated the following discrimination ability based on the area under the receiver operating characteristic curve (1 = perfect discrimination and 0.5 = chance) at 10 years in the surgical and nonsurgical groups, respectively: all-cause mortality (0.79 and 0.81), coronary artery events (0.66 and 0.67), heart failure (0.73 and 0.75), and nephropathy (0.73 and 0.76). When a patient’s data are entered into the IDC application, it estimates the individualized 10-year morbidity and mortality risks with and without undergoing metabolic surgery.

CONCLUSIONS

The IDC Risk Scores can provide personalized evidence-based risk information for patients with type 2 diabetes and obesity about future cardiovascular outcomes and mortality with and without metabolic surgery based on their current status of obesity, diabetes, and related cardiometabolic conditions.




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Coronary Artery Disease and Type 2 Diabetes: A Proteomic Study

OBJECTIVE

Coronary artery disease (CAD) is a major challenge in patients with type 2 diabetes (T2D). Coronary computed tomography angiography (CCTA) provides a detailed anatomic map of the coronary circulation. Proteomics are increasingly used to improve diagnostic and therapeutic algorithms. We hypothesized that the protein panel is differentially associated with T2D and CAD.

RESEARCH DESIGN AND METHODS

In CAPIRE (Coronary Atherosclerosis in Outlier Subjects: Protective and Novel Individual Risk Factors Evaluation—a cohort of 528 individuals with no previous cardiovascular event undergoing CCTA), participants were grouped into CAD (clean coronaries) and CAD+ (diffuse lumen narrowing or plaques). Plasma proteins were screened by aptamer analysis. Two-way partial least squares was used to simultaneously rank proteins by diabetes status and CAD.

RESULTS

Though CAD+ was more prevalent among participants with T2D (HbA1c 6.7 ± 1.1%) than those without diabetes (56 vs. 30%, P < 0.0001), CCTA-based atherosclerosis burden did not differ. Of the 20 top-ranking proteins, 15 were associated with both T2D and CAD, and 3 (osteomodulin, cartilage intermediate-layer protein 15, and HTRA1) were selectively associated with T2D only and 2 (epidermal growth factor receptor and contactin-1) with CAD only. Elevated renin and GDF15, and lower adiponectin, were independently associated with both T2D and CAD. In multivariate analysis adjusting for the Framingham risk panel, patients with T2D were "protected" from CAD if female (P = 0.007), younger (P = 0.021), and with lower renin levels (P = 0.02).

CONCLUSIONS

We concluded that 1) CAD severity and quality do not differ between participants with T2D and without diabetes; 2) renin, GDF15, and adiponectin are shared markers by T2D and CAD; 3) several proteins are specifically associated with T2D or CAD; and 4) in T2D, lower renin levels may protect against CAD.




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Inoreader v13 is Here With Improved Looks and New Features!

Since the beginning, Inoreader was meant to be a power-user tool, pushing the boundaries of what RSS readers can do.…




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Autologous Umbilical Cord Blood Transfusion in Young Children With Type 1 Diabetes Fails to Preserve C-Peptide

OBJECTIVE

We conducted an open-label, phase I study using autologous umbilical cord blood (UCB) infusion to ameliorate type 1 diabetes (T1D). Having previously reported on the first 15 patients reaching 1 year of follow-up, herein we report on the complete cohort after 2 years of follow-up.

RESEARCH DESIGN AND METHODS

A total of 24 T1D patients (median age 5.1 years) received a single intravenous infusion of autologous UCB cells and underwent metabolic and immunologic assessments.

RESULTS

No infusion-related adverse events were observed. β-Cell function declined after UCB infusion. Area under the curve C-peptide was 24.3% of baseline 1 year postinfusion (P < 0.001) and 2% of baseline 2 years after infusion (P < 0.001). Flow cytometry revealed increased regulatory T cells (Tregs) (P = 0.04) and naive Tregs (P = 0.001) 6 and 9 months after infusion, respectively.

CONCLUSIONS

Autologous UCB infusion in children with T1D is safe and induces changes in Treg frequency but fails to preserve C-peptide.




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Effectively Serving Immigrant and Dual Language Learner Families through Home Visiting Programs

Marking a policy brief's release, this webinar explores the promise of home visiting services that support new parents alongside their infants and toddlers, plus strategies for improving how these programs work with immigrant and linguistically diverse families.




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An Uneven Landscape: The Differing State Approaches to English Learner Policies under ESSA

Experts share how states have approached Every Student Succeeds Act (ESSA) implementation, areas where the law and state efforts to support English Learners can be improved, and findings from the compendium, The Patchy Landscape of State English Learner Policies under ESSA




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Seasonal Worker Programs in Europe: Lessons Learned and Ways Forward

As the European Union prepares to review the implementation of its Seasonal Workers Directive, as well as countries such as the United Kingdom continue to explore new approaches to selecting seasonal workers, this webinar features findings from a policy brief on the topic. 




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Humanitarian Protection in an Era of Pandemic

MPI and MPI Europe experts discuss the effects of the coronavirus pandemic on asylum systems in Europe and North America, as well as in developing regions, where 85 percent of refugees live. During this freeform conversation, our analysts also assess the implications for the principle of asylum and the future for a post-World War II humanitarian protection system that is under threat.
 




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A Study of Pregnancy and Birth Outcomes among African-Born Women Living in Utah

Resettled African refugee women may experience particularly acute complications during pregnancy, birth, and the child's early infancy. Yet health care-providers and policymakers may not be aware of the particular challenges that these women and their children face. This report, examining women giving birth in Utah over a seven-year period, compares perinatal complications of the African born and a segment of the U.S. born.




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In the Age of Trump: Populist Backlash and Progressive Resistance Create Divergent State Immigrant Integration Contexts

As long-simmering passions related to federal immigration policies have come to a full boil, less noted but no less important debates are taking place at state and local levels with regards to policies affecting immigrants and their children. As states are increasingly diverging in their responses, this report examines how some of the key policies and programs that support long-term integration success are faring in this volatile era.




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Mitigating the Effects of Trauma among Young Children of Immigrants and Refugees: The Role of Early Childhood Programs

The first years of a child’s life are a time of immense growth, and exposure to trauma—if left unaddressed—can have significant, lifelong effects. This issue brief examines how young children of refugees and other immigrants may be affected by trauma, and what early childhood education and care programs, health-care providers, and others can do to mitigate its adverse effects.




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Addressing Trauma in Young Children in Immigrant and Refugee Families through Early Childhood Programs

During this webinar, speakers provide an overview of an MPI policy brief that seeks to raise awareness of the intersection of trauma and early childhood development, and how U.S. early childhood programs could more effectively address this trauma in young children in refugee and immigrant households. The participants discuss efforts to integrate trauma-informed approaches into early childhood systems and how home visiting services can effectively address trauma and mental health through a two-generation approach.




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Immigrant Families and Child Welfare Systems: Emerging Needs and Promising Policies

With the children of immigrants a growing share of all U.S. children, and federal immigration enforcement and other policies undergoing significant change, some state and local child welfare agencies are developing new ways to improve how they work with immigrant families. This report examines key cultural, linguistic, and legal challenges, and how agencies are adjusting staffing, training, placement, and other policies to tackle them.




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Leveraging the Potential of Home Visiting Programs to Serve Immigrant and Dual Language Learner Families

Home visiting programs for young families are growing in popularity across the United States, and have demonstrated their effectiveness in supporting maternal health and child well-being. At the same time, more infants and toddlers are growing up in immigrant families and households where a language other than English is spoken. Why then are these children under-represented in these programs? This brief explores common barriers, ways to address them, and why it is important to do so.




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As U.S. Health-Care System Buckles under Pandemic, Immigrant &amp; Refugee Professionals Could Represent a Critical Resource

In a time of critical shortages of U.S. health-care workers during the COVID-19 pandemic, retired doctors are being called back to work and medical students are graduating on a fast track. There is another important pool that could be tapped: Immigrants and refugees who have college degrees in health fields but are working in low-skilled jobs or out of work. MPI estimates 263,000 immigrants are experiencing skill underutilization and could be a valuable resource.




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Can a Company be pro-regulation and pro-commerce? Gregg Renfrew from Beautycounter thinks so

It’s the middle of an election year and, according to the Pew Research Center, the country hasn’t been this polarized since the Civil War. In such a climate, it would seem to be an oxymoron for a company to push for both financial growth and tighter regulations. Gregg Renfrew, CEO & Founder of Beautycounter, wouldn’t […]




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Effects of Glycemic Control on Diabetes Complications and on the Prevention of Diabetes

Jay S. Skyler
Oct 1, 2004; 22:162-166
Feature Articles




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Medical Nutrition Therapy: A Key to Diabetes Management and Prevention

Sara F. Morris
Dec 1, 2010; 28:12-18
Feature Articles




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Diabetes and Back Pain: Markers of Diabetes Disease Progression Are Associated With Chronic Back Pain

Lorenzo Rinaldo
Jul 1, 2017; 35:126-131
Feature Articles




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Integration of Clinical Psychology in the Comprehensive Diabetes Care Team

Steven B. Leichter
Jul 1, 2004; 22:129-131
The Business of Diabetes




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Therapeutic Inertia is a Problem for All of Us

Stephen Brunton
Apr 1, 2019; 37:105-106
Editorials




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Diapression: An Integrated Model for Understanding the Experience of Individuals With Co-Occurring Diabetes and Depression

Paul Ciechanowski
Apr 1, 2011; 29:43-49
Feature Articles




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PROactive: A Sad Tale of Inappropriate Analysis and Unjustified Interpretation

Jay S. Skyler
Apr 1, 2006; 24:63-65
Commentary




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Interdisciplinary Team Care for Diabetic Patients by Primary Care Physicians, Advanced Practice Nurses, and Clinical Pharmacists

David Willens
Apr 1, 2011; 29:60-68
Feature Articles




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Insulin Strategies for Primary Care Providers

Karen L. Herbst
Jan 1, 2002; 20:
Feature Articles




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Application of Adult-Learning Principles to Patient Instructions: A Usability Study for an Exenatide Once-Weekly Injection Device

Gayle Lorenzi
Sep 1, 2010; 28:157-162
Bridges to Excellence




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Diabetes Self-Management in a Community Health Center: Improving Health Behaviors and Clinical Outcomes for Underserved Patients

Daren Anderson
Jan 1, 2008; 26:22-27
Bridges to Excellence




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Standards of Medical Care in Diabetes--2019 Abridged for Primary Care Providers

American Diabetes Association
Jan 1, 2019; 37:11-34
Position Statements




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Amylin Replacement With Pramlintide in Type 1 and Type 2 Diabetes: A Physiological Approach to Overcome Barriers With Insulin Therapy

John B. Buse
Jul 1, 2002; 20:
Feature Articles




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Standards of Medical Care in Diabetes--2016 Abridged for Primary Care Providers

American Diabetes Association
Jan 1, 2016; 34:3-21
Position Statements




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What's So Tough About Taking Insulin? Addressing the Problem of Psychological Insulin Resistance in Type 2 Diabetes

William H. Polonsky
Jul 1, 2004; 22:147-150
Practical Pointers




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A Real-World Approach to Insulin Therapy in Primary Care Practice

Irl B. Hirsch
Apr 1, 2005; 23:78-86
Practical Pointers




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Improving Patient Adherence

Alan M. Delamater
Apr 1, 2006; 24:71-77
Feature Articles




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Standards of Medical Care in Diabetes--2018 Abridged for Primary Care Providers

American Diabetes Association
Jan 1, 2018; 36:14-37
Position Statements




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Standards of Medical Care in Diabetes--2017 Abridged for Primary Care Providers

American Diabetes Association
Jan 1, 2017; 35:5-26
Position Statements




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Standards of Medical Care in Diabetes--2015 Abridged for Primary Care Providers

American Diabetes Association
Apr 1, 2015; 33:97-111
Position Statements




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The Pains of Progress

To measure time by how little we change is to find how little we've lived, 
but to measure time by how much we've lost is to wish we hadn't changed at all. Andre Aciman

The last frontier is not the Antarctic, or the oceans, or outer space. The last frontier is The Unknown. We mentioned in an earlier essay that uncertainty - which makes baseball and life interesting - is inevitable in the human world. Life will continue to be interesting as long as the world is rich in unknowns, waiting to be discovered. Progress is possible if propitious discoveries can be made. Progress, however, comes with costs.

The emblem of my university entwines a billowing smokestack and a cogwheel in the first letter of the institution's name. When this emblem was adopted (probably in 1951) these were optimistic symbols of progress. Cogwheels are no longer 'hi-tech' (though we still need them), and smoke has been banished from polite company. But our emblem is characteristic of industrial society which has seared Progress on our hearts and minds.

Progress is accompanied by painful tensions. On the one hand, progress is nurtured by stability, cooperation, and leisure. On the other hand, progress grows out of change, conflict, and stress. A society's progressiveness reflects its balance of each of these three pairs of attributes. In the most general terms, progressiveness reflects social and individual attitudes to uncertainty.

Let's consider the three pairs of attributes one at a time.

Change and stability. Not all change is progress, but all progress is change. Change is necessary for progress, by definition, and progress can be very disruptive. The disruptiveness sometimes arises from unexpected consequences. J.B.S. Haldane wrote in 1923 that "the late war is only an example of the disruptive result that we may constantly expect from the progress of science." On the other hand, progressives employ and build on existing capabilities. The entrepreneur depends on stable property rights before risking venture capital. The existing legal system is used to remove social injustice. Watt's steam engine extended Newcomen's more primitive model. The new building going up on campus next to my office is very disruptive, but the construction project depends on the continuity of the university despite the drilling and dust. Even revolutionaries exploit and react against the status quo, which must exist for a revolutionary to be able to revolt. (One can't revolt if nothing is revolting.) Progress grows from a patch of opportunity in a broad bed of certainty, and spreads out in unanticipated directions.

Conflict and cooperation. Conflict between vested interests and innovators is common. Watt protected his inventions with extensive patents which may have actually retarded the further development and commercialization of steam power. Conflict is also a mechanism for selecting successful ideas. Darwinian evolution and its social analogies proceed by more successful adaptations replacing less successful ones. On the other hand, cooperation enables specialization and expertise which are needed for innovation. The tool-maker cooperates with the farmer so better tools can be made more quickly, enhancing the farmer's productivity and the artisan's welfare. Conflicts arise over what constitutes progress. Stem cell research, genetic engineering, nuclear power technology: progress or plague? Cooperative collective decision making enables the constructive resolution of these value-based conflicts.

Stress and leisure. Challenge, necessity and stress all motivate innovation. If you have no problems, you are unlikely to be looking for solutions. On the other hand, the leisure to think and tinker is a great source of innovation. Subsistence societies have no resources for invention. In assessing the implications of industrial efficiency, Bertrand Russell praised idleness in 1932, writing: "In a world where no one is compelled to work more than four hours a day, every person possessed of scientific curiosity will be able to indulge it, and every painter will be able to paint without starving ...." Stress is magnified by the unknown consequences of the stressor, while leisure is possible only in the absence of fear.

New replaces Old. Yin and yang are complementary opposites that dynamically interact. In Hegel's dialectic, tension between contradictions is resolved by synthesis. Human history is written by the victors, who sometimes hardly mention those swept into Trotsky's "dustbin of history". "In the evening resides weeping; in the morning: joy." (Psalm 30:6). Change and stability; conflict and cooperation; stress and leisure.

No progress without innovation; no innovation without discovery; no discovery without the unknown; no unknown without fear. There is no progress without pain.



  • change and stability
  • conflict and cooperation
  • costs of progress
  • progress
  • stress and leisure

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Squirrels and Stock Brokers, Or: Innovation Dilemmas, Robustness and Probability

Decisions are made in order to achieve desirable outcomes. An innovation dilemma arises when a seemingly more attractive option is also more uncertain than other options. In this essay we explore the relation between the innovation dilemma and the robustness of a decision, and the relation between robustness and probability. A decision is robust to uncertainty if it achieves required outcomes despite adverse surprises. A robust decision may differ from the seemingly best option. Furthermore, robust decisions are not based on knowledge of probabilities, but can still be the most likely to succeed.

Squirrels, Stock-Brokers and Their Dilemmas




Decision problems.
Imagine a squirrel nibbling acorns under an oak tree. They're pretty good acorns, though a bit dry. The good ones have already been taken. Over in the distance is a large stand of fine oaks. The acorns there are probably better. But then, other squirrels can also see those trees, and predators can too. The squirrel doesn't need to get fat, but a critical caloric intake is necessary before moving on to other activities. How long should the squirrel forage at this patch before moving to the more promising patch, if at all?

Imagine a hedge fund manager investing in South African diamonds, Australian Uranium, Norwegian Kroners and Singapore semi-conductors. The returns have been steady and good, but not very exciting. A new hi-tech start-up venture has just turned up. It looks promising, has solid backing, and could be very interesting. The manager doesn't need to earn boundless returns, but it is necessary to earn at least a tad more than the competition (who are also prowling around). How long should the manager hold the current portfolio before changing at least some of its components?

These are decision problems, and like many other examples, they share three traits: critical needs must be met; the current situation may or may not be adequate; other alternatives look much better but are much more uncertain. To change, or not to change? What strategy to use in making a decision? What choice is the best bet? Betting is a surprising concept, as we have seen before; can we bet without knowing probabilities?

Solution strategies.
The decision is easy in either of two extreme situations, and their analysis will reveal general conclusions.

One extreme is that the status quo is clearly insufficient. For the squirrel this means that these crinkled rotten acorns won't fill anybody's belly even if one nibbled here all day long. Survival requires trying the other patch regardless of the fact that there may be many other squirrels already there and predators just waiting to swoop down. Similarly, for the hedge fund manager, if other funds are making fantastic profits, then something has to change or the competition will attract all the business.

The other extreme is that the status quo is just fine, thank you. For the squirrel, just a little more nibbling and these acorns will get us through the night, so why run over to unfamiliar oak trees? For the hedge fund manager, profits are better than those of any credible competitor, so uncertain change is not called for.

From these two extremes we draw an important general conclusion: the right answer depends on what you need. To change, or not to change, depends on what is critical for survival. There is no universal answer, like, "Always try to improve" or "If it's working, don't fix it". This is a very general property of decisions under uncertainty, and we will call it preference reversal. The agent's preference between alternatives depends on what the agent needs in order to "survive".

The decision strategy that we have described is attuned to the needs of the agent. The strategy attempts to satisfy the agent's critical requirements. If the status quo would reliably do that, then stay put; if not, then move. Following the work of Nobel Laureate Herbert Simon, we will call this a satisficing decision strategy: one which satisfies a critical requirement.

"Prediction is always difficult, especially of the future." - Robert Storm Petersen

Now let's consider a different decision strategy that squirrels and hedge fund managers might be tempted to use. The agent has obtained information about the two alternatives by signals from the environment. (The squirrel sees grand verdant oaks in the distance, the fund manager hears of a new start up.) Given this information, a prediction can be made (though the squirrel may make this prediction based on instincts and without being aware of making it). Given the best available information, the agent predicts which alternative would yield the better outcome. Using this prediction, the decision strategy is to choose the alternative whose predicted outcome is best. We will call this decision strategy best-model optimization. Note that this decision strategy yields a single universal answer to the question facing the agent. This strategy uses the best information to find the choice that - if that information is correct - will yield the best outcome. Best-model optimization (usually) gives a single "best" decision, unlike the satisficing strategy that returns different answers depending on the agent's needs.

There is an attractive logic - and even perhaps a moral imperative - to use the best information to make the best choice. One should always try to do one's best. But the catch in the argument for best-model optimization is that the best information may actually be grievously wrong. Those fine oak trees might be swarming with insects who've devoured the acorns. Best-model optimization ignores the agent's central dilemma: stay with the relatively well known but modest alternative, or go for the more promising but more uncertain alternative.

"Tsk, tsk, tsk" says our hedge fund manager. "My information already accounts for the uncertainty. I have used a probabilistic asset pricing model to predict the likelihood that my profits will beat the competition for each of the two alternatives."

Probabilistic asset pricing models are good to have. And the squirrel similarly has evolved instincts that reflect likelihoods. But a best-probabilistic-model optimization is simply one type of best-model optimization, and is subject to the same vulnerability to error. The world is full of surprises. The probability functions that are used are quite likely wrong, especially in predicting the rare events that the manager is most concerned to avoid.

Robustness and Probability

Now we come to the truly amazing part of the story. The satisficing strategy does not use any probabilistic information. Nonetheless, in many situations, the satisficing strategy is actually a better bet (or at least not a worse bet), probabilistically speaking, than any other strategy, including best-probabilistic-model optimization. We have no probabilistic information in these situations, but we can still maximize the probability of success (though we won't know the value of this maximum).

When the satisficing decision strategy is the best bet, this is, in part, because it is more robust to uncertainty than another other strategy. A decision is robust to uncertainty if it achieves required outcomes even if adverse surprises occur. In many important situations (though not invariably), more robustness to uncertainty is equivalent to being more likely to succeed or survive. When this is true we say that robustness is a proxy for probability.

A thorough analysis of the proxy property is rather technical. However, we can understand the gist of the idea by considering a simple special case.

Let's continue with the squirrel and hedge fund examples. Suppose we are completely confident about the future value (in calories or dollars) of not making any change (staying put). In contrast, the future value of moving is apparently better though uncertain. If staying put would satisfy our critical requirement, then we are absolutely certain of survival if we do not change. Staying put is completely robust to surprises so the probability of success equals 1 if we stay put, regardless of what happens with the other option. Likewise, if staying put would not satisfy our critical requirement, then we are absolutely certain of failure if we do not change; the probability of success equals 0 if we stay, and moving cannot be worse. Regardless of what probability distribution describes future outcomes if we move, we can always choose the option whose likelihood of success is greater (or at least not worse). This is because staying put is either sure to succeed or sure to fail, and we know which.

This argument can be extended to the more realistic case where the outcome of staying put is uncertain and the outcome of moving, while seemingly better than staying, is much more uncertain. The agent can know which option is more robust to uncertainty, without having to know probability distributions. This implies, in many situations, that the agent can choose the option that is a better bet for survival.

Wrapping Up

The skillful decision maker not only knows a lot, but is also able to deal with conflicting information. We have discussed the innovation dilemma: When choosing between two alternatives, the seemingly better one is also more uncertain.

Animals, people, organizations and societies have developed mechanisms for dealing with the innovation dilemma. The response hinges on tuning the decision to the agent's needs, and robustifying the choice against uncertainty. This choice may or may not coincide with the putative best choice. But what seems best depends on the available - though uncertain - information.

The commendable tendency to do one's best - and to demand the same of others - can lead to putatively optimal decisions that may be more vulnerable to surprise than other decisions that would have been satisfactory. In contrast, the strategy of robustly satisfying critical needs can be a better bet for survival. Consider the design of critical infrastructure: flood protection, nuclear power, communication networks, and so on. The design of such systems is based on vast knowledge and understanding, but also confronts bewildering uncertainties and endless surprises. We must continue to improve our knowledge and understanding, while also improving our ability to manage the uncertainties resulting from the expanding horizon of our efforts. We must identify the critical goals and seek responses that are immune to surprise. 






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How Technology Is Improving Safety On the Roads and Reducing Driving Anxiety

Technology has changed a number of aspects of our everyday lives and has led to increased efficiency. But when it comes to driving, has it helped or hindered the process? In this article, we will be looking into some of the ways that technology has improved safety on our roads in the last 10 years. […]




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How to Mentally Prepare for a Synchro Swimming Competition

Some people have the misguided belief that synchronized swimming is just an easy sport performed in beautiful swim team suits. That it’s merely dancing in the water that you can tune in to watch during the Olympic Games. But that is far from true; there is much more to the sport.  Synchro is a dominant […]




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Examining the Pros and Cons of Phone Therapy

Telephone therapy has taken on greater significance in the mental health industry in wake of the covid-19 pandemic. While some individuals may have avoided telephone therapy in the past, the temporary closure of mental health offices and the necessity of social distancing have resulted in an increasing number of people asking for more information on […]




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Prospect theory in the Moneyball movie

“I hate losing more than I even wanna win.” – Oakland Athletics General Manager Billy Beane (or some creative Hollywood writer channeling Billy Beane) Around 40 seconds in.




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How Do You Help a Partner Who is Depressed? Advice From a Sex Therapist

Depression is one of the most common mental health issues in the United States. In fact, according to the National Institutes of Mental Health, 1 in 14 Americans experienced an episode of major depression in the last year alone. Given the circumstances surrounding the current COVID-19 coronavirus pandemic, many in the mental health community predict that the number will be even higher this year because these circumstances are creating a “perfect storm” of depression risks. The widespread prevalence of depression has a lot of implications for our lives, even if we don’t personally have depression ourselves. Many of us will have loved ones, such as a romantic partner, who develops depression at some point. In these situations, it’s common for people to wonder how they can help their partner most effectively. So what should they do?




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Why it's so hard to talk about the N-word | Elizabeth Stordeur Pryor

Historian Elizabeth Stordeur Pryor leads a thoughtful and history-backed examination of one of the most divisive words in the English language: the N-word. Drawing from personal experience, she explains how reflecting on our points of encounter with the word can help promote productive discussions and, ultimately, create a framework that reshapes education around the complicated history of racism in the US.




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Why COVID-19 is hitting us now -- and how to prepare for the next outbreak | Alanna Shaikh

Where did the new coronavirus originate, how did it spread so fast -- and what's next? Sharing insights from the outbreak, global health expert and TED Fellow Alanna Shaikh traces the spread of COVID-19, discusses why travel restrictions aren't effective and highlights the medical changes needed worldwide to prepare for the next pandemic. "We need to make sure that every country in the world has the capacity to identify new diseases and treat them," she says. (Recorded March 5, 2020. Update: the CDC is now calling for everyone to wear face coverings in public.)




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How to create meaningful connections while apart | Priya Parker

Author Priya Parker shares tools for creating meaningful connections with friends, family and coworkers during the coronavirus pandemic -- and shows how we can take advantage of gatherings that are unique to this moment of social distancing. "We don't necessarily need to gather more," she says. "We need to gather better." (This virtual conversation is part of the TED Connects series, hosted by head of TED Chris Anderson and current affairs curator Whitney Pennington Rodgers. Recorded March 27, 2020)