Preponderance Of Evidence Research Articles

Comparing Stochastic and Deterministic Computing

Technology scaling has raised the specter of myriads of cheap, but unreliable and/or stochastic devices that must be creatively combined to create a reliable computing system. This has renewed the interest in computing that exploits stochasticity-embracing, not combating the device physics. If a stochastic representation is used to implement a programmable general-purpose architecture akin to CPUs, GPUs, or FPGAs, the preponderance of evidence indicates that most of the system energy will be expended in communication and storage as opposed to computation. This paper presents an analytical treatment of the benefits and drawbacks of adopting a stochastic approach by examining the cost of representing a value. We show both scaling laws and costs for low precision representations. We also analyze the cost of multiplication implemented using stochastic versus deterministic approaches, since multiplication is the prototypical inexpensive stochastic operation. We show that the deterministic approach compares favorably to the stochastic approach when holding precision and reliability constant.

Psychopharmacologic Agents to Enhance Cognition in Alzheimer’s Disease

Cognitive dysfunction in people with Alzheimer’s disease (AD) significantly affects their interactions, independence, behavior, health, wellness, and quality of life; care providers also experience quality of life issues as a result. This review summarizes clinical data on agents associated with cognitive enhancement in AD, particularly the currently approved anti-AD medications including the acetyl cholinesterase inhibitors (ChEIs) (donepezil, galantamine, and rivastigmine) and the N-methyl-d-aspartate antagonist, memantine. Initiation and maintenance of stage-appropriate monotherapy or combination therapy with a ChEI and memantine provides the best pharmacologic approach to stem the expected inexorable course of cognitive decline. Discontinuation of agents that impair cognition and treatment of comorbid conditions (eg, sleep disorders, dehydration, depression, anxiety, pain, as well as metabolic, hormone, and vitamin derangements) may also improve cognition. The preponderance of evidence regarding ChEIs, memantine, and vitamin E strongly supports modest, but clinically relevant, “disease-course modifying” effects of cognitive enhancement (eg, improvement, stabilization, or shifting of the trajectory of cognitive or functional decline) in patients who receive appropriate and persistent treatment. [ Psychiatr Ann . 2015;45(7):354–367.]

Determining causation of work-related upper extremity disorders.

To determine causation in work-related upper extremity disorders, one must appreciate the philosophical constructs used in establishing causation and have clear definitions of the disorder in question. The preponderance of evidence does not support repetition as a major risk factor for physical injury. Terms such as "repetitive stress," "repetitive strain," and "cumulative trauma" should be abandoned, and we should educate our patients as to the multiple risk factors for upper extremity pain.

Efficacy of Psychosocial Interventions in Men Over 55

Whether psychosocial treatments work equally well for late middle-aged and older men and women is unknown. For this critical review, sixteen studies were identified that examined psychosocial treatments for psychopathology in men age 55 and older. The preponderance of evidence showed that treatments worked at least as well in men as in women. Six studies reported statistically significant treatment effects in exclusively male participants. Methodological problems include weak research designs, small sample size, and absence of indication of clinical significance. There continues to be a paucity of research addressing the efficacy of psychosocial interventions for late middle-aged and older men. Researchers are encouraged to include racially and ethnically diverse older men in carefully controlled studies that examine clinically significant change.

Risk and safety of probiotics.

Probiotics have been used safely for years. Safety outcomes are inconsistently reported in published clinical trials. In 2011, a report released by the Agency for Healthcare Research and Quality concluded that, although the existing probiotic clinical trials reveal no evidence of increased risk, "the current literature is not well equipped to answer questions on the safety of probiotics in intervention studies with confidence." Critics point out that the preponderance of evidence, including the long history of safe probiotic use as well as data from clinical trials, and animal and in vitro studies all support the assumption that probiotics are generally safe for most populations. Theoretical risks have been described in case reports, clinical trial results and experimental models, include systemic infections, deleterious metabolic activities, excessive immune stimulation in susceptible individuals, gene transfer and gastrointestinal side effects. More research is needed to properly describe the incidence and severity of adverse events related to probiotics.

Approach to the postoperative patient with Cushing's disease.

Cushing's disease is a neuroendocrine disorder marked by hypercortisolemia secondary to overproduction of ACTH by a corticotropic pituitary adenoma. Due to the diverse and deleterious effects of hypercortisolemia including diabetes mellitus, hypertension, and cardiovascular disease, prompt and accurate diagnosis followed by surgical resection of the responsible corticotropic adenoma is critical. In the following review, we present a focused synopsis of recently published data and management strategies for the post-operative Cushing's disease patient with a particular focus on studies examining perioperative complications, establishment of biochemical remission, factors associated with disease remission, and predictors of recurrence. Although no standard definition of remission exists, we suggest measurement of serum cortisol level on the morning of postoperative day 1 given the preponderance of evidence in the published literature suggesting its association with long-term remission and relatively low rates of recurrence. Nevertheless, all patients should be counseled that recurrence can occur in a delayed fashion and that annual endocrine testing should be utilized to track and confirm disease status.

Viewpoint: a response to "Screening and isolation to control methicillin-resistant Staphylococcus aureus: sense, nonsense, and evidence".

Surveillance and isolation for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) has become a controversial topic, one that causes heated debate and appears to be surrounded by both politics and industrial conflicts-of-interest. There have been calls from numerous authors for a movement away from rigid mandates and toward an evidence-based medicine approach. However, much of the evidence can be viewed with an entirely different interpretation. Two major studies with negative findings have had an adverse impact on recommendations regarding active detection and isolation (ADI) for MRSA. However the negative findings in these studies can be explained by shortcomings in study implementation rather than the ineffectiveness of ADI. The use of daily chlorhexidine bathing has also been proposed as an alternative to ADI in ICU settings. There are shortcomings regarding the evidence in the literature concerning the effectiveness of daily chlorhexidine bathing. One of the major concerns with universal daily chlorhexidine bathing is the development of bacterial resistance. The use of surveillance and isolation to address epidemics and common dangerous pathogens should solely depend upon surveillance and isolation’s ability to prevent further spread to and infection of other patients through indirect contact. At present, there is a preponderance of evidence in the literature to support continuing use of surveillance and isolation to prevent the spread of MRSA.

Understanding how income influences willingness to pay for joint programs: A more equitable value measure for the less wealthy

The preponderance of evidence from many studies is that less wealthy households are subjected to greater exposure per capita and in aggregate to air pollution, water pollution, and toxic wastes. It also is the case that the less wealthy are provided with a disproportionately low amount of other programs to enhance amenities provided by the natural environment, such as recreational resources and high-quality esthetic opportunities (both quality and quantity). However, to date, no study has quantified the scale of this effect on the less wealthy as compared to their more wealthy counterparts when it comes to policy choices made on the basis of benefits analysis. This study provides a new equity adjustment method to measure quantitatively the effect of this inequity in the case of public goods.

Transparency of Values in Science: Elliott and Resnik Respond

We thank Schwartz for his thoughtful comments, which provide an opportunity for us to clarify some of the points in our commentary, in which we called for greater transparency about the values that influence policy-relevant research (Elliott and Resnik 2014). His first concern is that even though we call for employing different standards of evidence in various social contexts, the evidence itself remains the same. We agree; in our commentary we were not claiming that the evidence itself changes but only that the form of evidence required for different decisions depends on the social context. Nevertheless, it is important to recognize that although the evidence itself does not change, it has to be interpreted and weighed, and many contemporary science policy disputes stem from disagreements about how to do so (Douglas 2012). Therefore, our view is that conflicts over public policies often stem from value judgments about both the nature of the evidence and standards of evidence. We agree with Schwartz about the solution: Transparency is essential. The more scientists acknowledge the assumptions and values that influence their interpretations of evidence and their decisions about how to weigh it, the better. Schwartz’s second point is that it is problematic for us to treat tort law and chemical regulations as equivalent contexts, in which weaker standards of evidence can appropriately inform policy. We agree that different standards of evidence may be appropriate in the two contexts. However, we caution against equating the standards of evidence expected in tort law with those expected in more traditional scientific contexts. The tort system requires only a preponderance of evidence (> 50% likelihood) to win a case; this is much weaker evidence than scientists typically demand when presenting or publishing results, and confusion about these differing standards has led to significant legal controversies (Cranor 2006). Schwartz’s third point is that other conflicts of interest, such as “ideological ties to advocacy organizations,” are important to disclose in addition to financial ties to industry. We heartily agree; indeed, in our commentary (Elliott and Resnik 2014) we stated that “Disclosures of competing financial interests and nonfinancial interests (such as professional or political allegiances) also provide opportunities for more transparent discussions” (Elliott and Resnik 2014). One of the aims of our commentary was to encourage more careful thinking about how to promote transparency regarding a wide range of different factors that could influence scientists’ reasoning, including ideology. Nevertheless, there are at least two reasons that financial connections to industry groups should continue to receive careful attention: a) Advocacy organizations typically have much fewer resources than industry to generate policy-relevant research that serves their interests (Elliott 2011); and b) a large body of evidence indicates that industry funding has important effects on research outcomes, whereas there is less information about how ideological ties affect research (e.g., Lundh et al. 2012). Schwartz’s fourth concern is that it is important to think about risk–benefit relationships when applying science to public policy. This is a very good point, but it needs to be considered in conjunction with the fact that scientists’ values and assumptions may influence their assessments of the evidence. It would be ideal if scientists could provide perfectly unbiased risk assessments to policy makers, who could then evaluate the risks versus the benefits in order to make policy decisions. Unfortunately, this picture is unrealistic; scientists’ views about the benefits associated with new technologies likely have implicit influences on their risk assessments. For example, evidence from the literature on risk perception indicates that people’s perceptions of risk are influenced by a number of factors, including the voluntariness of the risks, the fairness of their distribution, their familiarity, and the perceived benefits associated with them (Fischhoff et al. 1981). Scientists are subject to these same influences, especially when they have limited data or are forced to weigh multiple forms of evidence (Cooke 1991). This provides further support for our central claim, namely, that scientists should explore ways to acknowledge the values that may influence them rather than denying the presence of these influences.

Paleotsunami evidence on Kaua‘i and numerical modeling of a great Aleutian tsunami

The Hawaiian Islands' location in the middle of the Pacific Ocean is threatened by tsunamis from great earthquakes in nearly all directions. Historical great earthquakes Mw > 8.5 in the last 100 years have produced large inundations and loss of life in the islands but cannot account for a substantial (≤ 600 m3) paleotsunami deposit in the Makauwahi sinkhole on the Island of Kaua‘i. Using high‐resolution bathymetry and topography we model tsunami inundation of the sinkhole caused by an earthquake with a moment magnitude of Mw ~9.25 located in the eastern Aleutians. A preponderance of evidence indicates that a giant earthquake in the eastern Aleutian Islands circa 1425–1665 A.D.—located between the source regions of the 1946 and 1957 great tsunamigenic earthquakes—created the paleotsunami deposit in Kaua‘i. A tsunami deposit in the Aleutians dated circa 1530–1660 A.D. is consistent with this eastern Aleutian source region.

Anchored in Reality or Blinded by a Paradigm: The Roleof Cap-Weighted Indices in the Future

In this article, the author examines the long rise and recent rethinking of cap-weighted indices. The research suggests their widespread adoption was propelled both by cap-weighted market indices—capital asset pricing model (CAPM)—theory and exceptional returns in the 1980s and 1990s. Yet since 1999, performance has faltered, and the preponderance of evidence indicates that cap-weighted market indices are not necessarily the be all and end all for investors. Going forward, exposures to cap-weighted indices will need to be balanced, weighed, and combined with other exposures such as those related to size, value, volatility, etc. A simple portfolio solution, like a cap-weighted market index, is not likely to be optimal for all investors, and investment committees probably will need to revise and update their policy portfolios, performance measurement, and compensation schemes. The skill of active management will be defined relative to these new policy portfolios, not cap-weighted benchmarks.

Transformational leadership to promote interprofessional practice

Background: Evidence has been generated and synthesized to support enhanced outcomes in healthcare environments supportive of interprofessional practice. Despite the preponderance of evidence, many health professions educational programs do not prepare their students for interprofessional practice. Objective: Participants will be able to: 1) Identify evidence supporting the benefits of interprofessional practice. 2) Discuss transformational leadership strategies to facilitate cross-institutional collaboration. 3) Evaluate resources needed and methods to overcome barriers to successful cross-institutional collaborations. Methods: Transformational leadership techniques have been used to replace health profession and institutional silos with interprofessional and cross-institutional collaboration in Fort Worth, Texas, USA. Faculty from TCU (Texas Christian University) and the UNTHSC (University of North Texas Health Science Center) are collaborating to create interprofessional training opportunities for health professions students. Faced with the growing need to teach and assess interprofessional team and patient care skills, an innovative collaboration has been developed to promote cross-institutional interprofessional faculty development, curriculum planning, and shared interprofessional educational (IPE) activities. Results: This cross-institutional collaboration has allowed for the development of integrated health care student teams broadening the interprofessional experiences for students of both institutions. Shared faculty, facilities, and resources have enhanced student IPE experiences. New IPE opportunities develop as interprofessional cross-institutional faculty develop relationships through shared faculty development and working together to plan student IPE activities. Discussion: The session will describe this unique cross-institutional collaboration by institutional representatives directly involved in the development of this partnership to advance interprofessional research, education, and practice. The results of this partnership include funded projects, joint conference training, multi-profession simulations, mutual faculty and student training, and cross-institutional IPE curriculum planning. Conclusion: The transformational leadership strategies used to advance this work will be discussed. Challenges, benefits, supporting resources, and success strategies used to advance the strategic objectives of this cross-institution interprofessional education collaboration will be identified.

Final reports of the Stardust Interstellar Preliminary Examination

AbstractWith the discovery of bona fide extraterrestrial materials in the Stardust Interstellar Dust Collector, NASA now has a fundamentally new returned sample collection, after the Apollo, Antarctic meteorite, Cosmic Dust, Genesis, Stardust Cometary, Hayabusa, and Exposed Space Hardware samples. Here, and in companion papers in this volume, we present the results from the Preliminary Examination of this collection, the Stardust Interstellar Preliminary Examination (ISPE). We found extraterrestrial materials in two tracks in aerogel whose trajectories and morphology are consistent with an origin in the interstellar dust stream, and in residues in four impacts in the aluminum foil collectors. While the preponderance of evidence, described in detail in companion papers in this volume, points toward an interstellar origin for some of these particles, alternative origins have not yet been eliminated, and definitive tests through isotopic analyses were not allowed under the terms of the ISPE. In this summary, we answer the central questions of the ISPE: How many tracks in the collector are consistent in their morphology and trajectory with interstellar particles? How many of these potential tracks are consistent with real interstellar particles, based on chemical analysis? Conversely, what fraction of candidates are consistent with either a secondary or interplanetary origin? What is the mass distribution of these particles, and what is their state? Are they particulate or diffuse? Is there any crystalline material? How many detectable impact craters (>100 nm) are there in the foils, and what is their size distribution? How many of these craters have analyzable residue that is consistent with extraterrestrial material? And finally, can craters from secondaries be recognized through crater morphology (e.g., ellipticity)?

Including “Evidentiary Balance” in News Media Coverage of Vaccine Risk

Journalists communicating risk-related uncertainty must accurately convey scientific evidence supporting particular conclusions. Scholars have explored how “balanced” coverage of opposing risk claims shapes uncertainty judgments. In situations where a preponderance of evidence points to a particular conclusion, balanced coverage reduces confidence in such a consensus and heightens uncertainty about whether a risk exists. Using the autism–vaccine controversy as a case study, we describe how journalists can cover multiple sides of an issue and provide insight into where the strength of evidence lies by focusing on “evidentiary balance.” Our results suggest that evidentiary balance shapes perceived certainty that vaccines are safe, effective, and not linked to autism through the mediating role of a perception that scientists are divided about whether a link exists. Deference toward science, moreover, moderates these relationships under certain conditions. We discuss implications for journalism practice and risk communication.

The empirical foundations of telemedicine interventions for chronic disease management.

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

How does coffee prevent liver fibrosis? biological plausibility for recent epidemiological observations

The published epidemiological data demonstrating an inverse relationship between coffee (and potentially other caffeinated beverage) consumption and liver fibrosis and its downstream complications are weighty and rapidly accumulating. Several excellent recent reviews examine this evidence in great detail (1–3), and the overwhelming conclusion is that this inverse relationship is real – coffee drinking reduces liver fibrosis. Among the strongest studies to support this observation are the findings that, after adjustment for confounders, individuals in the highest quintile of caffeine consumption had less than one third the risk of ALT elevation of those in the lowest quintile (odds ratio (OR) 0.31, 95% CI 0.16–0.61) (4) and, perhaps more importantly, advanced liver fibrosis from chronic liver diseases of various etiologies is associated with reduced coffee and total caffeine consumption (5) with one study showing that the odds of having cirrhosis decreased with increasing daily consumption of coffee in a step-wise manner from an OR of 0.47 (95% CI 0.20–1.10) for patients consuming 1 cup of coffee per day to an OR of 0.16 (95% CI 0.05–0.50) for patients consuming 4 cups per day, compared to lifetime abstainers as the reference (OR 1.0) (6). Demonstrating the clinical significance of coffee consumption, Freedman and colleagues found that among patients with advanced fibrosis, those who consumed no coffee had a risk of hepatic decompensation or hepatocellular carcinoma (HCC) of 11.1 per 100 patient-years compared to just 6.3 per 100 patient-years in those consuming ≥ 3 cups of coffee per day, with no beneficial effect seen with tea or other sources of caffeine (7). Coffee consumption has also been shown to be associated with a lower risk of fatty liver disease (8), metabolic syndrome (9), and ultimately hepatocellular carcinoma (10). As a clinician or scientist interested in the pathogenesis of liver fibrosis, one may very well ask whether these findings are of great value.

Influence of physical activity on bone strength in children and adolescents: a systematic review and narrative synthesis.

A preponderance of evidence from systematic reviews supports the effectiveness of weight-bearing exercises on bone mass accrual, especially during the growing years. However, only one systematic review (limited to randomized controlled trials) examined the role of physical activity (PA) on bone strength. Thus, our systematic review extended the scope of the previous review by including all PA intervention and observational studies, including organized sports participation studies, with child or adolescent bone strength as the main outcome. We also sought to discern the skeletal elements (eg, mass, structure, density) that accompanied significant bone strength changes. Our electronic-database, forward, and reference searches yielded 14 intervention and 23 observational studies that met our inclusion criteria. We used the Effective Public Health Practice Project (EPHPP) tool to assess the quality of studies. Due to heterogeneity across studies, we adopted a narrative synthesis for our analysis and found that bone strength adaptations to PA were related to maturity level, sex, and study quality. Three (of five) weight-bearing PA intervention studies with a strong rating reported significantly greater gains in bone strength for the intervention group (3% to 4%) compared with only three significant (of nine) moderate intervention studies. Changes in bone structure (eg, bone cross-sectional area, cortical thickness, alone or in combination) rather than bone mass most often accompanied significant bone strength outcomes. Prepuberty and peripuberty may be the most opportune time for boys and girls to enhance bone strength through PA, although this finding is tempered by the few available studies in more mature groups. Despite the central role that muscle plays in bones' response to loading, few studies discerned the specific contribution of muscle function (or surrogates) to bone strength. Although not the focus of the current review, this seems an important consideration for future studies.

Risk of dementia after anaesthesia and surgery: study design may affect reported outcome

Although not highlighted in their paper, the results of Chen et al [1][1] are fundamentally different from the preponderance of evidence that suggests a lack of association, as summarised in recent systematic reviews and a large case-control study.[2][2]-[4][3] This is an important topic that is

Reply to M.C. Chamberlain

Cancer and Leukemia Group B (CALGB) 50202 was the first clinical trial to demonstrate the feasibility of dose-intensive consolidative chemotherapy in the multicenter setting for newly diagnosed patients with primary CNS lymphoma (PCNSL). The CALGB 50202 regimen consists of a novel induction regimen, consisting of twice-weekly high-dose methotrexate1,2 in combination with weekly rituximab,3–6 plus monthly temozolomide (MT-R).7–9 Rituximab is administered for six doses, during the first 6 weeks of induction, an interval during which the blood-brain barrier may be most significantly disrupted by angiotropic lymphoma.10,11 Patients who achieved a complete response to MT-R received high-dose, infusional etoposide in combination with twice-daily, high-dose cytarabine, over 4 days12–16 (Table 1). Two thirds of the patients achieved a complete response with MT-R induction, the median progression-free survival (PFS) at 2 years was 59%, the median PFS was 4 years and the 4-year overall survival probability was 65%. As noted in the editorial17 that accompanies the article, the results of 50202 are comparable or superior to results obtained in other prospective multicenter trials that included whole-brain radiotherapy. Notably, the striking PFS of those who completed consolidation dose-intensive chemotherapy replicates the institutional experience with this regimen in PCNSL, dating to 2001.13 Moreover, for the first time in a clinical trial in PCNSL, patients age 60 years or older had outcomes similar to younger patients, highlighting another significant advantage of the dose-intensive consolidation approach used in 50202 compared with consolidative whole-brain radiotherapy. The recent finding that patients with PCNSL age 60 years or older have inferior outcomes with even reduced-dose whole-brain radiotherapy would seem to further underscore the advantage of dose-intensive chemotherapeutic consolidation.18 Regarding the question of whether CALGB 50202 is practice-changing, considering the outcomes obtained with the 50202 regimen in the multicenter setting, and the preponderance of evidence that brain radiotherapy, even at reduced doses, is neurotoxic19–21 and associated with a long-term increased risk of de novo secondary brain neoplasms,22,23 we ask the question, what hematologist/oncologist, neurologist, or patient with PCNSL would recommend or prefer to receive whole-brain radiotherapy, at any dose, as consolidation in first remission, if dose-intensive chemotherapeutic consolidation is available as an option? Table 1. CALGB (Alliance) 50202 Regimen To address the comments of Chamberlain24 regarding the rationale for the number of cycles of methotrexate used, and the role of rituximab, temozolomide and etoposide, we suggest a review of the explanations and references provided in the text of the manuscript and in Table 1 of this letter, as well as an assessment of the outcomes of patients treated in CALGB 50202 (Fig 2 of the publication), with a 2-year PFS that is without precedent in a multicenter study involving chemotherapy without brain radiotherapy in PCNSL.25,26 In regards to the number of doses of cytarabine at consolidation, Chamberlain should note that similar schedules of high-dose cytarabine actually are in fact used to treat other hematologic malignancies that are associated with poor prognosis, such as mantle-cell lymphoma and acute myelogenous leukemia.27–31 We certainly agree with Chamberlain, however, that there is a significant need to improve the 50202 regimen and advocate that the best means to contribute to this effort and to enhance outcomes for PCNSL patients is via active participation in prospective clinical trials such as CALGB 51101, the successor and an intergroup study and first randomized trial for PCNSL that does not involve brain radiotherapy. Notably, given the correlative end points embedded within the trial, participation in this important study by the hematology/oncology and neuro-oncology community will also significantly enhance our understanding of the patient with PCNSL's quality of life and disease biology, creating a foundation for trials that address molecular targets and prognostic risk groups and lead to further improvements in outcomes in this previously highly refractory form of non-Hodgkin lymphoma.32

Disentangling the Effect of Top Management Support and Training on Systems Implementation Success: A Meta-Analysis

Systems implementation is an important topic, and numerous studies have been conducted to identify determinants of success. Among organizational factors that can have an impact on success, top management support and training are two of the most extensively studied variables. While the positive influence of both of these organizational factors is generally recognized, not all empirical evidence is supportive. Some researchers attribute the inconsistent findings to moderators such as task interdependence. Other researchers contend that the wide-ranging correlations observed in different studies are caused by nothing but statistical artifacts. Still another reason for the inconsistent results could be how the two variables are modeled. I meta-analyzed thirty prior studies that examine the effect of both top management support and training. The results support both independent variables having a moderate positive effect on implementation success. Additionally, they suggest that the most plausible model is one where training partially mediates the effect of top management support. Finally, the preponderance of evidence indicates that task interdependence does not moderate the effect of either top management support or training. Instead, the role of task interdependence is similar to that of top management support and training: as an independent variable with a direct effect on implementation success.