Burnout is a psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that has been found to exist in a significant number of healthcare and helping professionals. It imposes a significant societal burden by shortened practitioner lifespan, decreased efficiency, negative health outcomes and poorer levels of patient care. Theoretical models suggest that it appears to be the result of a complex interaction between job resources and job demands. It may be reasonable to conclude that Chiropractic professionals experience similar vocational demands and thus experience significant levels of occupational stress and subsequent burnout. However the data on burnout within the chiropractic profession is limited. It is possible that this results in significant negative outcomes on chiropractors and their patients. Therefore, the objective of this paper is to demonstrate the need to explore burnout in chiropractic practice and offer a research protocol for a potential study. Past research has sought to explore and quantify the elevated levels of stress and susceptibility to burnout found in the helping professions. This has been demonstrated in professionals that share many similar characteristics to chiropractic such as medical practitioners ,2, dentiFactors that have been identified which increase levels of stress and susceptibility to burnout include constantly focusing on the needs of others, which may lead to fatigue, feelings of frustration and anger, a sense of ineffectiveness and failure, and the onset of depression and associated co-morbidities ,19-22. OWith this body of evidence available for comparison it would seem logical to explore those significant factors already identified. Therefore, the objective of this paper is to demonstrate the need to explore burnout in chiropractic practice and to propose a research protocol for a potential study. Thus we would seek to question a representative selection of chiropractors from varying locations on their perceptions of the impact of these factors using an established and validated questionnaire.In 2008 there were 49,100 registered chiropractors in the U.S.; of these approximately 44% were self-employed . While tAgainst this backdrop is the unfavourable public perception of chiropractic when compared with mainstream medicine with regard to ethics and honesty: in a 2006 Gallup Poll of U.S. adults, chiropractors were rated last among seven health care professions for being very high or high in honesty and ethical standards .th least stressful occupation in the USA in 2011 [CareerCast.com rates chiropractic as the 10 in 2011 . They baThis perception would stand in contrast to a retrospective analysis  of licenA cursory glance on affiliated contemporary chiropractic material suggests that stress and burnout are salient and important issues. The first discussion on burnout was noted in 1987 in an ICA Review of Chiropractic . ShelleyThe authors contend that this milieu, and other factors, create high levels of vocational stress and may generate high levels of burnout. However there are mixed messages from the available information sources and to date there has been no research into this sizable and significant occupational group.Although burnout and stress are separate concepts, it has been a commonly held belief that the cumulative effect of chronic stress often results in a condition known as burnout . This haFirst, burnout can negatively affect the chiropractic professional and in turn the quality of care delivered to the patient. Burnout has been implicated in poor patient outcomes in other caring professions ,12. It iSecond, Mertz et al. (2010) suggest that most non-practicing chiropractors believed that the practice of chiropractic medicine was not a good career choice and would not recommend someone choosing chiropractic as a vocation . ResearcThird, this is a preventable syndrome ,37. EarlThe authors contend that with such potentially serious and long-term consequences, this issue can no longer be left unexplored in the chiropractic profession.The purpose of the intended study is to learn more about the levels of stress and burnout in the chiropractic profession. The specific objectives are to measure their prevalence and to compare those to levels previously identified and quantified in helping professions similar to the chiropractic profession.The authors intend to approach the appropriate chiropractic registration bodies with a request for assistance in distributing a mail out questionnaire to their membership. A pre-paid envelope with return address will be included. An alternative on-line survey option will also be made available.For example, access to email listings of chiropractors is available for academic/educational purposes via a request through the State Board of Chiropractic Examiners, NJ. The investigators could request the email contact information of a randomized sample of licensed chiropractors from the State of New Jersey, State Board of Chiropractic Examiners, thus ensuring a systematic random sampling of the population of interest.Subjects will include any Doctor of Chiropractic currently licensed to practice chiropractic and whom is at least 21 years old; with no limit on maximum age criteria.Assuming a 60% return rate, the investigators will request the email contact information of a randomized sample of at least 500 licensed chiropractors in order to obtain sufficient numbers for the appropriate statistical analysis to be performed.While the term "burnout" has become quite common in both research and practice, it has been ill defined historically. Initially, the term burnout was introduced by Freudenberger in the 1970's, and was used as an informal expression by lawyers, social workers, psychiatrists, teachers and hospice counsellors, to denote their gradual energy depletion and loss of motivation and commitment that was often associated with a wide array of other physical and mental symptoms ,44.http://www.mindgarden.com/products/mbi.htm.Maslach's 1982) definition of burnout is now the most influential and widely referenced . It is d definitiRespondents will also be asked to complete a second questionnaire that contains demographic questions  and open-ended questions related to chiropractic-specific stressors, as previously found in the literature. Examples of these include issues such as poor public perception, professional-identity inconsistencies, philosophical dissonance, negative media coverage, workplace injury levels from unique physical demands, market competition from other manual therapists, student loan default rates in North America and threats to autonomy ,47,48.An email letter of solicitation will be send to the random sample of emails via a group email distribution. This letter of solicitation will be in the body of the email and contain a link to an online version of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and a brief demographic questionnaire developed by the primary investigator. SURVEY MONKEY (Gold member) software will be the electronic medium used. The Consent to Participate page shall include the title and purpose of the project, procedures for the anonymous and voluntary nature of the survey and potential risks and benefits to participants. The participants will complete the surveys in a place of their choice , which has access to a computer. The Principal Investigator (PI) will conduct his portion of the research at York College, 94-20 Guy R. Brewer Blvd, Jamaica, NY 11451.All survey related data will be stored on a thumb drive, which will be stored in locked cabinet at the place of research. After a minimum of 3 years, the PI will destroy the information on the thumb drive.This study is conducted with an observational research design that will involve the use cross-sectional data collection as a means of establishing the prevalence of burnout among chiropractors and to examine its association with some potential risk factors.The primary analysis will involve descriptive summary statistics  and inferential statistics  for estimating the prevalence of burnout. The use of univariate analysis using t-tests and chi-square statistic will be utilized to compare the rate of burnout with the factors under investigation. Chiropractic-specific stressors will be correlated using Pearson correlation. Moreover, the relationship between the dimensions of burnout and ratio-level demographic variables will be tested using bivariate Pearson correlational analyses. Spearman's rho analyses will we used for ordinal-level data. To control for possible confounding factors, a multiple logistic regression will be utilized with burnout as the dependent variable.Research ethics and ethics approval will be sought from the principal investigators academic institution at the School of Health & Behavioral Sciences, CUNY - York College, New York, United States of America. All responses will be kept completely confidential and investigator(s) will be blinded to response and subject identity connectors.Chiropractors are significant members of the health care community. Past studies have shown that the health care profession population experiences high levels of stress and burnout. Previous studies have identified ameliorable factors, which can result in the implementation of effective interventions with outcomes that include improved levels of patient care and practitioner health measures. No such exploration has been offered in the chiropractic profession; consequently an evidence-based intervention is not possible. The authors contend that now is the time.U.S.: United States: EE: Emotional exhaustion; DP: Depersonalization; PA: Personal accomplishment; PI: Principle investigator.The authors declare that they have no competing interests.SW is the PI of the proposed study, and the original proposal author. SI added content expertise and editorial modifications. Both authors read and approve the final version of the manuscript.


Many health care disciplines use evidence-based decision making to improve patient care and system performance. While the amount and quality of emergency medical services (EMS) research in Canada has increased over the past two decades, there has not been a unified national plan to enable research, ensure efficient use of research resources, guide funding decisions and build capacity in EMS research. Other countries have used research agendas to identify barriers and opportunities in EMS research and define national research priorities. The objective of this project is to develop a national EMS research agenda for Canada that will: 1) explore what barriers to EMS research currently exist, 2) identify current strengths and opportunities that may be of benefit to advancing EMS research, 3) make recommendations to overcome barriers and capitalize on opportunities, and 4) identify national EMS research priorities.Paramedics, educators, EMS managers, medical directors, researchers and other key stakeholders from across Canada will be purposefully recruited to participate in this mixed methods study, which consists of three phases: 1) qualitative interviews with a selection of the study participants, who will be asked about their experience and opinions about the four study objectives, 2) a facilitated roundtable discussion, in which all participants will explore and discuss the study objectives, and 3) an online Delphi consensus survey, in which all participants will be asked to score the importance of each topic discovered during the interviews and roundtable as they relate to the study objectives. Results will be analyzed to determine the level of consensus achieved for each topic.a priori concerns.A mixed methods approach will be used to address the four study objectives. We anticipate that the keys to success will be: 1) ensuring a representative sample of EMS stakeholders, 2) fostering an open and collaborative roundtable discussion, and 3) adhering to a predefined approach to measure consensus on each topic. Steps have been taken in the methodology to address each of these  Evidence-based medicine is the "...conscientious, explicit, and judicious use of current best evidence in making decisions...". The praEMS has traditionally focused on emergency response to the sick and injured in the prehospital environment, and inter-facility transport. The last three decades have seen considerable expansion of the scope of practice of EMS personnel and the sophistication of EMS operations. EMS systems and paramedics are now seen as integral parts of the health care system, with their roles expanding to include not only emergency response and transport, but injury prevention and control, community health, public education, and emergency preparedness . This exA foundation of research is required to support an evidence-based approach to prehospital care. While progress has been made in developing this foundation, EMS research is still in its infancy. The further development of Canadian EMS research has been identified by key stakeholders as a priority .National EMS Research Agenda, developed through multidisciplinary discussions and iterative expert writing and reviews, was published [National EMS Research Strategic Plan, which identified priority areas for EMS research [The research enterprise in EMS, like other health disciplines, is fraught with barriers and opportunities ,5. Otherublished . This seresearch .While the EMS systems of Australia and the United States share some commonalities with Canada, such as paramedic-based EMS systems, there are also many significant differences, such as how practitioners are trained, funding mechanisms both for practice and for research, and infrastructure. Research barriers, opportunities, and priorities may not be generalizable from these countries to Canada due to the unique constellation of factors that have a profound impact on the provision of EMS services and the research enterprise, and the time that has lapsed since the Australian and US agendas were published. To that end, we have undertaken the development of an EMS research agenda for Canada. Here we report our methodology with the intent that it may serve as an important starting point for other countries that are attempting to define their research agenda and improve the effectiveness and efficiency of their research enterprise.To ensure that the Canadian National EMS Research Agenda is produced using an evidence- based approach that reflects the diversity of EMS systems in Canada, a three-phase mixed methods study has been designed. The project will consist of: 1) qualitative baseline interviews, 2) a facilitated roundtable discussion among key informants, and 3) a Delphi consensus survey. The results of each phase will inform subsequent phases.The study team will develop a list of stakeholder categories of potential participants who may be able to provide important input to the study Table . Purposeth, 2011 and in the Delphi consensus survey, which will be conducted after the results of the roundtable discussion are available.Potential participants will be emailed an invitation letter and participant response form. Of those participants who return the participant response form, a sub-sample will be contacted by email, specifically recruiting them to participate in the qualitative baseline interviews. All participants will be invited to participate in the roundtable discussion in St. John's, Newfoundland, Canada on June 8Research ethics board approval was received for the qualitative interviews from St. Michael's Hospital, Toronto ON Canada (11-011c), and for the roundtable session and consensus survey from the Capital District Health Authority, Halifax NS Canada (CDHA-RS/2011-248).For the telephone qualitative baseline interviews, informed consent will be verbally obtained by the interviewer (KD). For the roundtable discussion and consensus survey, participants will complete a written informed consent procedure prior to the roundtable discussion.The purpose of this phase is to gain a baseline understanding of the perspective of key stakeholders with regard to the landscape of EMS research in Canada in order to provide a framework for the roundtable discussion. Areas of interest include: the barriers and opportunities in EMS research; recommendations for enhancing the research enterprise; and topic areas within EMS research believed to be a high priority.A qualitative key informant interview study will be conducted, using one-on-one semi-structured telephone interviews with a sub-sample of the invited participants.Ideally, the total sample will consist of 3-4 members of each key group, and invited organizations, for a total of ~ 20 participants. There will also be an attempt to have as diverse a representation from all provinces, EMS system types and professional types  as possible.The sub-sample of invited participants will be sent an email which explains the qualitative study and includes a letter of information and invitation to participate. The lead investigator of the qualitative study (KD) will obtain verbal consent and conduct the interviews with those who volunteer. The purposeful sampling technique will be complemented with snowball sampling by asking interviewees to identify individuals who they feel should be added to the sample.An interview guide will be developed, based on the information from the literature and the areas of interest for the study. All interviews will be conducted by telephone for consistency, and the interviewer will use the study guide along with additional probing questions to facilitate the interviews. Interviews will be audio recorded for verbatim transcription and analysis and the interviewer will take supplemental field notes during the conversation. Data collection will be considered complete once saturation is reached; that is, when little new information is expected to be learned from further interviews .Two investigators (KD and BB) will conduct the qualitative data analysis using a constant comparative method . AnalysiA summary of the results of the analysis will be shared with all interviewees to engage them in any clarifications required to ensure the summary document accurately includes their input to the study . The finThe purpose of the roundtable key informant discussion is to gather a purposeful sample of key stakeholders (the participants) from across Canada to discuss the four study objectives: to further identify and discuss barriers and opportunities for Canadian EMS research, make recommendations for the future, and identify research priorities.Participants will be provided with preliminary results from the baseline qualitative study prior to the roundtable session. An in depth review of the findings will also be presented at the session. In addition, a US EMS researcher will present information on his experiences as a member of the team that set the US EMS Research Agenda (LB) .The roundtable session will be based on the methodology of a successful meeting that set a Canadian EMS agenda for Patient Safety in 2010 . The rouParticipants will be purposefully placed into small groups. Each group will contain a mix of participants from different participant categories, with careful attention paid to creating groups that are geographically diverse. A facilitator will be assigned to each table, and will lead the small groups by encouraging participants to openly discuss their thoughts on each study objective. Small group facilitators will move discussions forward by using probing questions to explore topics identified by the participants. Small group facilitators will meet with the professional facilitator prior to the roundtable session to ensure that an appropriate and consistent approach is taken to the small group facilitation. The professional facilitator and two group facilitators will also circulate amongst the small groups during the session to listen to the conversations and ensure a uniform approach is being taken by all small group facilitators.Each participant will complete the written informed consent procedure, a disclosure of conflict of interest form and a short demographic questionnaire, for the purpose of accurately reporting sample characteristics.For each of the four objectives, participants will break into their assigned small groups. All small groups will be provided with flipcharts, where they will record topics discussed related to each objective. In addition, every participant will be provided worksheets for each study objective, in which they can list all topics they feel are important for each objective. These worksheets will be collected. After the completion of each small group session, the large group will re-convene and share topics and items that emerged during small group discussion. An investigator will record all topics reported verbally.After the completion of the roundtable, two investigators (JJ & RB) will review all the recorded information from the day, and will organize the topics into the four project objectives. Duplicate items in a category will be removed. Original participant wording will be maintained as much as possible, for use in the subsequent Delphi consensus survey .The purpose of the Delphi consensus survey is to identify, using participant consensus, the most important topics in each of the four study objectives.Delphi studies are frequently used in healthcare and other industries  to achieWithin four weeks of the roundtable session, participants will be emailed a link to an online survey site. Each survey round will be open for five working days. In the first round, topics identified in the literature synthesis, qualitative interviews and roundtable session will be listed for each study objective . An additional text box will be provided for respondents to enter any further topics, thoughts or elaborations they have. Participants will score each topic on a Likert scale .In the second and third rounds, the mean scores for each topic and the participant's own score will be available for review . Participants will be able to re-score each topic, or keep the score they assigned in the previous round. As consensus is reached on the 'importance'   into a Microsoft Excel spreadsheet , in which descriptive analysis of panel characteristics, categorization of free text, and analysis (mean scores and level of consensus) of each topic in each round will be conducted.a priori [most important items if 80% of the participants scored the theme as 4 ('important') or 5 ('extremely important'). These topics will be removed from the list in subsequent rounds. In a similar fashion, consensus for the least important topics will be considered achieved if 80% or more of the participants score any topic a 1 ('not important') or a 2 ('not very important'). For each round, analysis for consensus will be conducted for the entire panel, and also for participant stratifications of the panel .In Delphi surveys, it is essential to define consensus a priori . For eacResponse rates for each round will be reported, as well as descriptive statistics of the participant demographics.To achieve the objectives of the Canadian National EMS Research Agenda a mixed methods approach will be used. This approach of collecting both qualitative and quantitative data to answer one research question is growing in popularity among researchers and funding agencies . An esseThe final report will include the results of the qualitative findings from the baseline interviews, quantitative results from the roundtable and Delphi consensus survey, and the results of the triangulation exercise. The integration of these results will form the Canadian EMS Research Agenda.Graham et al (2006) coined the term 'knowledge to action' to describe the meaning and components of the knowledge translation process . KnowledA multi-faceted dissemination plan targeted at stakeholders will be executed at the completion of the Agenda project. The primary means of conveying the results of the study will be through publication of peer-reviewed manuscripts in journals that appeal to the target scientific and provider audience. Second, submissions will be made to prominent EMS trade journals targeting front-line paramedics, medical directors and EMS operators. Third, presentations at regional, provincial, and national EMS conferences will be used to communicate the results to attendees. Lastly, key organizations will be notified of the results and asked to convey them to their members through free electronic media and posting of the results on their free-access websites. As well the research agenda will be circulated to potential granting agencies, foundations, industrial and academic partners and follow up meetings with these constituents will enable full discussion and identify opportunities to lobby for change, influence priority and new funding initiatives.Once the Agenda has been widely disseminated in Canada, it is expected it will serve as a guide for EMS stakeholders to implement a local and national strategy to address barriers to research and to maximize on existing and future opportunities. It may be used to inform budget planning and grant allocation and human resources for research, and to lobby for change in the way funding is directed in existing funding agencies. The implementation strategy is likely to include efforts to develop and protect researchers to conduct studies on questions found to be important, and will ignite collaboration across the country, which will allow for studies with sample sizes sufficient to answer vital questions.Once this study is complete, and results are disseminated through the mediums described above, we anticipate challenges in the following components of the knowledge translation action cycle: adaptation to the local context, monitoring knowledge use, and evaluating the outcomes of using the knowledge. EMS systems in Canada have had variable research experiences, ranging from no exposure to studies to being involved with the conduction of randomized controlled trials. Because of this variability, the implementation of the Canadian EMS Research Agenda will need to be adapted to individual services and settings. Local research stakeholders will need to review the Agenda and determine which barriers, opportunities, recommendations and research priorities make the most sense to adopt. The extent of implementation of the agenda will be determined through surveys and networking events, which will provide opportunities to capitalize on funding and partnership opportunities to conduct research. The ultimate goal of the Agenda is to improve patient care and EMS system delivery through the creation and use of meaningful and high quality EMS research. Possible benchmarks include grant funding acquired, publications, clinical outcomes , cost savings, and the number of EMS systems actively involved in research.a priori concerns.In this comprehensive mixed methods study, we anticipate the keys to success will be: 1) ensuring a representative sample of EMS stakeholders, 2) fostering an open and collaborative roundtable discussion, and 3) adhering to a predefined approach to measure consensus on each topic. Steps have been taken in the methodology to address each of these The findings of this study will provide leaders in EMS administration, regulation, medical direction, academia, clinical practice, government funding agencies, foundations and industrial partners with critical evidence to further strengthen Canadian EMS research.EMS: emergency medical servicesJLJ and AC receive salary support from Emergency Health Services to conduct EMS research. IEB receives salary support from Alberta Health Services - EMS to conduct EMS research. EC receives salary support from Dalhousie University to direct and conduct EMS research. AMC receives salary support from the City of Toronto to conduct research and has received travel support from ZOLL Medical. KND receives salary support to conduct research from grant funding. LJM is an investigator with the Resuscitation Outcomes Consortium (ROC). ZOLL Medical Inc, Phillips and Medtronic have a partnership agreement with the NIH, which sponsors ROC. Their agreement pertains to the provision of equipment and software to the participating EMS and Fire Services. A portion of LJM's salary support is provided by the NIH Grant that supports the U of T ROC Regional Coordinating Centre. LJM holds grants from Canadian Institute of Health Research, Heart and Stroke Foundation Canada, American Heart Association, Laerdal Medical Foundation and the Ontario Ministry of Health. No other author has a financial or academic conflict of interest to disclose in regard to this study topic.JLJ, IEB, BLB and DS developed the research concept and plan. JLJ and KD obtained research ethics approval. JLJ, IEB, BLB, DS obtained funding. JLJ, IEB, BLB, DS, KD and RB recruited and enrolled participants. All authors contributed substantially to the design and methodology of this study and to the writing and critical editing of this manuscript, and intend to remain significantly involved in the study until completion. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-227X/11/15/prepub


China has the largest numbers of cancer patients worldwide but has limited pathology resources. According to a survey done by Chinese Pathologists Association, a large number of pathologists in clinical practice in China has only one year of formal or informal training. Only in recent year, formal pathology residency programs similar to those of Western countries are available in a couple of large medical schools, where limited numbers of well-trained and experienced pathologists are located. When having rare or complex cancer pathology cases, pathologists often have difficulty in making an accurate diagnosis. Mistakes in cancer diagnosis are not uncommon, which often leads to inadequate treatment of patients and medical legal problems. Thus, there is a great need for pathology consultation and quality control of cancer diagnosis in China.In recent years, telepathology or digital pathology has been applied in many areas of pathology, including remote consultation and quality control . Difficuhttp://www.mpathology.cn) was designed to serve as the hub for the project, connecting hospitals and expert consultants. Selection an internet based platform or a website portal was due to the consideration that multiple hospitals/institutions and multiple expert pathologists from different institutions need to access the platform. A server was used for storage of images and data. Figure An internet based telepathology consultation platform . The virtual microscope and related software were tested and validated previously in a study involving a variety of 600 surgical pathology specimens in China. The study showed a high concordance rate (94.2%) between WSI and H/E glass slide .http://www.mpathology.cn). Experts were provided with a unique identifier and access code to the website. For telepathology consultation, the expert was instantly informed by the cell phone message and e-mail once he/she was requested for consult. The expert pathologist would use a computer or an Ipad to log into the website, check out the pending cases for consultation under his/her name, review WSI of the case, capture a representative image from WSI to included in the final report, type in pathologic features of the case, write up his/her opinion and provide a final diagnosis. After that, he/she would preview the final report, then sign the report with an electronic signature and then release the final report.356 pathologists with provincial and national reputation volunteered to participate in the program. 80 of them were selected to serve as expert consultants after passing an online assessment consists of 30 pathology consultation cases in WSI format. The names, affiliation of the pathologists and the areas of their subspecialty expertise were listed on the website (Once the final consultation report was released, the system sent an email to alert the system manager. The final consultation report was then sent by the system manger by e-mail or fax to the referring pathologist.87 hospitals in 17 provinces where national healthcare reform was carried out volunteered to participate the phase I of the program, all of the hospitals had more than 6000 pathology cases annually. Pathologists in those hospitals took an online diagnostic test of 50 cases of cancer. Those hospitals having pathologists with excellent test results were eliminated from the program. 60 hospitals were finally selected to participate in the phase I of the program. Participating hospitals were given a unique identification code and user name to login to the website platform. Pathologists of the participating hospitals are required to receive a short period of training, which includes operation of the virtual microscope and internet connection to the platform. Storage and security of the WSI, relevant clinical data, and consultation files are also to be addressed.For telepathology consultation, each participating hospital is required to send WSI of at least 300 cases annually for second opinion. The number of cases is set at about 15% to 20% of cancer diagnosed each year in those hospitals. Hospitals can choose pathologists for second opinion or consultation from 80 expert consultants with different subspecialty expertise. For quality control of pathology diagnosis, the participating hospitals are required to submit WSI of every cancer diagnosed to the platform. Quality control is to be carried out by expert consultants every 3 month on 10% randomly selected cases. The accuracy of cancer diagnosis and quality of tissue section are to be reviewed, assessed, and submitted to provincial and national pathology quality control centers. The results of the phase I of the program are to be used to guide future deployment of the program across the country.Since 2009, due to the wide spread use of high speed internet and availability of low cost virtual microscopes in China, telepathology has gained attention from academic institutions and government. In 2010, the Ministry of Health of China released an announcement encouraging hospitals to use telepathology for cancer diagnosis and planned to develop a nationwide telepathology consultation service and quality control program. The plan is to set up in each province a provincial telepathology consultation and pathology quality control network, which also connects to a central national network. The goal of the plan is to facilitate remote consultation for cancer diagnosis and to monitor the accuracy of pathological diagnosis of cancer. In 2011, the phase I of the plan consisting of 60 hospitals in 17 provinces was completed.In China, we do not know the exact number of error in pathological diagnosis of cancer, however, we believe the rate is much higher than those reported in Western countries, as many pathologists in China are not as well trained as those in Western countries and many pathologists in China do not have subspecialty expertise. The project we design asks participating hospitals to submit all of their newly diagnosed cancer cases. 10% of those cases will be randomly selected for review. The 10% is set arbitrarily and is not a high percentage for newly diagnosed cancer cases, in comparison to prospectively secondly review of all newly diagnosed cancer cases or retrospective mandatory review of all cancer cases by some institutions in North America.et al. [et al. [et al. [Second opinion or consultation is extremely important in pathology diagnosis, especially in cancer diagnosis. In a retrospectively review of consultation cases of urological malignancy, Wayment et al.  reported [et al.  review t [et al.  found a  [et al.  reportedThrough this program, we believe that in near future telepathology will be widely used in China for pathology consultation and quality control. The program will not only assists pathologists in dealing with diagnostically difficult pathology cases, but also benefits patients, who do not need to travel a long distance to large hospitals for a second opinion of cancer diagnosis, thus saving time and money for patients. The program will also guaranty the quality of pathology diagnosis of cancer in China.


In the year 2020, depression will cause the second highest amount of disability worldwide. One quarter of the population will suffer from depression symptoms at some point in their lives. Mental health services in Western countries are overburdened. Therefore, cost-effective interventions that do not involve mental health services, such as online psychotherapy programs, have been proposed. These programs demonstrate satisfactory outcomes, but the completion rate for patients is low. Health professionals’ attitudes towards this type of psychotherapy are more negative than the attitudes of depressed patients themselves. The aim of this study is to describe the profile of depressed patients who would benefit most from online psychotherapy and to identify expectations, experiences, and attitudes about online psychotherapy among both patients and health professionals that can facilitate or hinder its effects.A parallel qualitative design will be used in a randomised controlled trial on the efficiency of online psychotherapeutic treatment for depression. Through interviews and focus groups, the experiences of treated patients, their reasons for abandoning the program, the expectations of untreated patients, and the attitudes of health professionals will be examined. Questions will be asked about training in new technologies, opinions of online psychotherapy, adjustment to therapy within the daily routine, the virtual and anonymous relationship with the therapist, the process of online communication, information necessary to make progress in therapy, process of working with the program, motivations and attitudes about treatment, expected consequences, normalisation of this type of therapy in primary care, changes in the physician-patient relationship, and resources and risks. A thematic content analysis from the grounded theory for interviews and an analysis of the discursive positions of participants based on the sociological model for focus groups will be performed.Knowledge of the expectations, experiences, and attitudes of both patients and medical personnel regarding online interventions for depression can facilitate the implementation of this new psychotherapeutic tool. This qualitative investigation will provide thorough knowledge of the perceptions, beliefs, and values of patients and clinicians, which will be very useful for understanding how to implement this intervention method for depression. Reports from the World Health Organization say that depression will cause the second highest level of disability worldwide by the year 2020 . It is aThe term “computer-assisted psychotherapy” is used to refer to any psychotherapy program  that uses the patient’s responses to perform some type of decision-making about treatment . This ted) when analysed by intention to treat and 1 (Cohen’s d) when only the patients who complete the program are analysed. In addition, effectiveness is maintained 6 months after finishing the therapy program [In the specific case of depression, studies show that computer-assisted psychotherapy is effective for the treatment of light and moderate depression . This re program . Other c program .This type of therapy produces a very positive expectation in patients and a high degree of satisfaction ,21. HoweThe first objective of this research is to describe the profile of depressed patients who would benefit the most from online-assisted psychotherapy. The second objective is to identify expectations, experiences, and attitudes among both patients and health professionals that may serve as barriers to or facilitators of online-assisted psychotherapy by considering the types of information that they require throughout the therapeutic process for adequate intervention development.A qualitative study in the context of a randomised controlled trial on the effectiveness of an online psychotherapeutic intervention for depression is proposed. Through in-depth interviews , first, The study will be performed in the Spanish autonomous communities of Andalucía, Aragón, and Baleares. The patients will be recruited during visits to a primary care physician, and diagnosis will be established using the MINI Neuropsychiatric Interview in Spanish . All parA preliminary analysis will allow us to progress though the interviews in an iterative manner until the data are saturated; that is, until the new information becomes redundant and provides no new perspectives. We hope that this will occur after approximately 10 interviews in each of the four groups . After the interviews, four focus groups will be conducted, each consisting of between eight and ten subjects. An attempt will be made to ensure the adequate representation of the stratification variables considered but with intergroup heterogeneity and intragroup homogeneity to allow the groups to be formed appropriately ,30. The The researchers involved in the study will receive training in qualitative social research procedures, in-depth interviews, and focus groups . Topics We will seek to achieve optimum standardisation in the sessions with a specification guide with open and flexible content Table  while alWe will ensure the confidentiality and anonymous nature of the study for potential participants. All of the sessions will be audio taped with the consent of the participating subjects, and the material will be transcribed verbatim. Both the interviews and the focus groups will last approximately 60–90 minutes. The two researchers responsible for the focus groups will meet after each session to clarify and exchange views and field notes. This information will be analysed with data from the audio recordings and notes .The body of text (verbatim) will consist of recordings transcribed literally, supplemented by notes from observations and comments from interviewers/moderators and collaborators. The interviewers/moderators will verify the transcripts to guarantee the accuracy of the data. Final validation will be performed by inviting the participants to read and discuss the transcribed content .The preliminary analysis will begin after the first interviews and progress through the interviews iteratively to confirm or discount the topics found . The traThe information gathered from focus groups will be analysed using the model of sociological analysis ,45. In tTo manage the data, we will use the analysis program MAXQDA 2007. The results of the thematic content analysis of the interviews and the interpretation of the main explanatory axes in the focus groups will be presented alongside the empirical references in the text, selecting the most representative verbatim segments for use as examples. The researchers will develop a list of concepts identified in the interviews and focus groups and create conceptual diagrams that increase understanding and comparability. The final coding framework will be discussed with the main researcher and therapy coordinator so that all stakeholders agree.Online computer-assisted psychotherapy seems to be an effective and cost-effective approach to treating mild to moderate depression ,16-18. IQualitative research methods provide a thorough understanding of the perceptions, beliefs, and values of the people being studied, and they are very useful in the health field ,49. ThesThe authors declare that they have no competing interests.JM-M, JMC, ASB, MR, MG, RB, CB, RA and JG-C conceptualised the study. JM-M wrote the manuscript and all authors participated in critically revising for important intellectual content and have given final approval of the version to be published.Jesús Montero-Marín, Javier García-Campayo, Miquel Roca, Antoni Serrano-Blanco, Margalida Gili, Fermín Mayoral, Juan V. Luciano, Yolanda López del Hoyo and Bárbara Oliván belong to the REDIAPP .The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/13/64/prepub


The availability of high-density panels of SNP markers has opened new perspectives for marker-assisted selection strategies, such that genotypes for these markers are used to predict the genetic merit of selection candidates. Because the number of markers is often much larger than the number of phenotypes, marker effect estimation is not a trivial task. The objective of this research was to compare the predictive performance of ten different statistical methods employed in genomic selection, by analyzing data from a heterogeneous stock mice population.For the five traits analyzed , within-family predictions were more accurate than across-family predictions, although this superiority in accuracy varied markedly across traits. For within-family prediction, two kernel methods, Reproducing Kernel Hilbert Spaces Regression (RKHS) and Support Vector Regression (SVR), were the most accurate for W6W, while a polygenic model also had comparable performance. A form of ridge regression assuming that all markers contribute to the additive variance (RR_GBLUP) figured among the most accurate for WGS and BL, while two variable selection methods  had the greatest predictive abilities for %CD8+ and CD4+/ CD8+. RF, RKHS, SVR and RR_GBLUP outperformed the remainder methods in terms of bias and inflation of predictions.Methods with large conceptual differences reached very similar predictive abilities and a clear re-ranking of methods was observed in function of the trait analyzed. Variable selection methods were more accurate than the remainder in the case of %CD8+ and CD4+/CD8+ and these traits are likely to be influenced by a smaller number of QTL than the remainder. Judged by their overall performance across traits and computational requirements, RR_GBLUP, RKHS and SVR are particularly appealing for application in genomic selection. The availability of high-density panels of single nucleotide polymorphisms (SNP) containing thousands of markers opened new perspectives for the study of complex diseases, while has enhanced marker-assisted selection strategies in animal and plant breeding.The possibility to predict accurately the genetic merit of selection candidates based on their genotypes for SNP markers, a process known as genomic selection , is revoDespite this, the amount of information to be analyzed in this situation poses new challenges from statistical and computational viewpoints. As the number of predictor variables (markers) is generally much higher than the number of observations (phenotypes), there is lack of degrees of freedom to estimate all marker effects simultaneously, what is aggravated by the fact that models may suffer from multicollinearity, especially because markers in close positions are expected to be highly correlated.According to review in , some ofThere are still few extensive studies aimed to compare predictive performance of the such methods in plants or in animals . In the Thus, the objective of this research was to compare the predictive performance of ten different statistical methods employed in genomic selection by using data from a heterogeneous stock mice population, aiming to provide some insight in the scope of statistical methods useful for genomic selection and in the interplay between the genetic background of traits and the performance of these methods.http://gscan.well.ox.ac.uk). Briefly, this population was generated from the crossing of eight inbred lines, followed by 50 generations of random mating. As a result, this population exhibits a high level of linkage disequilibrium, even for pairs of markers separated by until 2Mb   8] analyFor within-family predictions, as a general rule, predictive abilities were between 19% and 40% lower in the present study than in comparable situations reported by  and 8]  8] what On the other hand, for %CD8+, emBayesB, BayesCpi and LASSO achieved predictive abilities 4%, 6% and 10% greater, respectively, than that obtained with RJMCMC under within-family prediction . These aWhile simulation studies suggest that variable selection methods  could outperform methods with assumptions close to those of GBLUP e.g. ,4,27), t,27, t4,2In the present study, methods with large conceptual differences reached very similar predictive abilities in some situations and a clear re-ranking of methods was observed in function of the trait analyzed. In other species, it has also been verified that methods with different assumptions had similar performance e.g. ,30,5), w,5, w30,5Overall, for at least one of the five traits analyzed in present study, most of the methods figured among the most accurate, being that the only exception was observed for SS_BY and SS_ABS, reason why these methods do not seem to be recommendable for application in genomic selection.One important point that needs to be taken into account when comparing methods employed in genomic selection is that their performance is often influenced by key parameters required in their implementations, like the assignment of prior distributions in Bayesian regression methods and setting tuning parameters of machine learning methods. In this way, such parameters can be optimized for each situation analyzed in order to improve predictive performance.Although we expected that the implementations of the LASSO  and emBayes (in which parameters related to the distribution of marker effects are estimated from the data) also could fit well to QTL distribution, results of excess kurtosis suggest that statistical learning was more effective in the case of BayesCpi, although some drawbacks were found for this method, especially in terms of bias.Even though RKHS, SVR and RF figured among the best methods in some of the situations analyzed, some of their tuning parameters were not optimized for each trait, due to the additional computational effort that would be required by this task, in a way that their performance might still be improved.According to , predictIt is also important to mention that in the present study the phenotypes used in model training were pre-corrected for environmental effects in order to reduce computing times, as well as the target phenotypes in the validation sets, what is not an optimal approach from a statistical perspective and could be an additional source of noise in the present results. For instance, in the case of overcorrection for some fixed effect in the validation set, it would be expected that methods that lead to more shrunk estimates of marker effects perform better in terms of bias and inflation in this situation.Specifically with respect to SVR, this method had the lower overall accuracy among the ten methods studied by  when conIt has been suggested that the accuracy of BayesCpi is not strongly affected by the starting value of π  and evenHeslot et al.  also poiThe optimal method for genomic selection should be reliable across traits and computationally efficient, besides, obviously, being the highest accurate possible and less prone to overfitting . Some auGiven the imminent increase in dimensionality of genomic selection problems, due to both increase in the number of genotyped animals and especially in the density of marker panels , it is mIt seems to be consensual that accuracy of genomic predictions is dependent on the genetic architecture of traits , as well as on the size of the training set, the number of independent chromosome segments (which is function of genome size and effective population size), the heritability of (pseudo)phenotypes used to train models and the marker density e.g. ,25)..25]).QTL), while the accuracy of methods based on variable selection is expected to be greater than that of GBLUP when NQTL is lower than the number of independent chromosome segments.Regarding to the relative performance of the prediction methods, Daetwyler et al.  suggesteQTL).In the present study, the predictive abilities were considerably greater in the case of within-family predictions when compared to across-family predictions, what was also reported by  and 7]..7]. DespAnother hypothesis for the differences in the superiority of within-family predictions across traits, also mentioned by , is thatEspecially for W6W, the relatively good performance of POL and the different pattern for the of distribution of estimated marker effects in variable selection methods could be indicative of a more polygenic background than for the other traits.In the other extreme, based on the previous results regarding QTL mapping of these traits  and giveIt has been advocated RKHS, SVR and RF are able to capture complex interactions (e.g. dominance and epistatic effects), in a way that could be hypothesized that part of their predictive ability could be due to such interactions, although it can be difficult to confirm this theory, given the difficulty to model interactions explicitly. It is worth to emphasize that in this case these methods predict genotypic values rather than purely additive breeding values.Within-family predictions, as defined in this study, are more similar to the situation expected in most of animal breeding applications , becauseAnother important question regarding to the predictive ability of genomic prediction methods regards to its variation across subpopulations or families. In the present study, there was some evidence that such differences in predictive ability are trait-specific, being that for the two traits for which suggestive differences between groups in predictive ability were found under some methods, phenotypic variances also differed between these groups. Thus, conversely to what was pointed out by , there wAccording to , groups Some authors argue that genotyping by whole-genome resequencing will become a regular practice in the near future ,36. As tMethods with large conceptual differences reached very similar predictive abilities in some situations and a clear re-ranking of methods was observed in function of the trait analyzed. For all traits and situations analyzed, at least two of the genomic prediction methods lead to more accurate predictions than the polygenic model.Variable selection methods were more accurate than the remainder in the case of %CD8+ and CD4+/CD8+ and these traits are likely to be influenced by a smaller number of QTL than the remainder. Judged by their overall performance across traits and computational requirements, RR_GBLUP, RKHS and SVR are particularly appealing for application in genomic selection.The authors declare that they have no competing interests.HHRN participated in the design of the study, carried out data analysis, participated in analysis of results and drafted the manuscript. RC participated in the design of the study, analysis of results and drafted the manuscript. SAQ participated in the design of the study and analysis of results and drafted the manuscript. All authors read and approved the final manuscript.


Dementia is increasing in prevalence as the population ages. An earlier rather than later diagnosis allows persons with dementia and their families to plan ahead and access appropriate management. However, most diagnoses are made by general practitioners (GPs) later in the course of the disease and are associated with management that is poorly adherent to recommended guidelines. This trial examines the effectiveness of a peer led dementia educational intervention for GPs.The study is a cluster randomised trial, conducted across three states and five sites. All GPs will complete an audit of their consenting patients aged 75 years or more at three time points - baseline, 12 and 24 months. GPs allocated to the intervention group will receive two educational sessions from a peer GP or nurse, and will administer the GPCOG to consenting patients at baseline and 12 months. The first education session will provide information about dementia and the second will provide individualised feedback on audit results. GPs in the waitlist group will receive the RACGP Guidelines by post following the 12 month auditOutcomes: Primary outcomes are carer and consumer quality of life and depression. Secondary outcomes include: rates of GP identification of dementia compared to a more detailed gold standard assessment conducted in the patient's home; GP identification of differential diagnoses including reversible causes of cognitive impairment; and GP referral to specialists, Alzheimers' Australia and support services. A "case finding" and a "screening" group will be compared and the psychometrics of the GPCOG will be examined.Sample size: Approximately 2,000 subjects aged 75 years and over will be recruited through approximately 160 GPs, to yield approximately 200 subjects with dementia (reducing to 168 by 24 months).The trial outlined in this paper has been peer reviewed and supported by the Australian National Health and Medical Research Council. At the time of submission of this paper 2,034 subjects have been recruited and the intervention delivered to 114 GPs.ACTRN12607000117415.Australia and New Zealand Clinical Trials Register (ANZCTR):  Dementia is an increasingly common condition largely due to increasing longevity of the population in Australia, and other countries. Approximately 1 in 5 Australians over the age of 80 have some form of dementia . Consequ2010 Intergenerational Report estimates that Australian Government spending on aged care will increase from 0.8 per cent of GDP in 2010 to 1.8 per cent by 2050  and for a correlation of 0.80 .We aim to recruit 2000 subjects, based on a dementia prevalence rate of 10% in the Australian population aged 75 years and over . We antiWe do not anticipate a high drop-out rate of GPs, as the demands on GPs are not onerous. As patients are consented separately to GPs, patients can continue even if their GPs withdraw from the study.All surveys collected on laptop computers will be downloaded to a central database. Where necessary in the analysis, the longitudinal and hierarchical/cluster nature of the study design will be taken into account using mixed effects models and other appropriate methods (see below). The primary analysis will be by intention to treat. Analyses will address the following questions:Detection rates of GPs trained in using the GPCOG (the Intervention group) will be compared with detection rates of Waitlist GPs against the 'gold standard' of the CAMCOG.Differential diagnoses (particularly of depression), of the Intervention group will be compared with those of the Waitlist group. Misclassification rates of the GPs in the Intervention group will be compared with those in the waitlist group.Outcomes measured will include identification of reversible causes of dementia, tests ordered and referral patterns to specialists, support services and Alzheimer's Australia, as suggested in the guidelines.Outcomes of Intervention and Waitlist groups will be compared at twelve months, for both patients and their carers All subjects and support persons will be asked to rate the acceptability of the screening instrument and procedures. Descriptive analysis will be performed. Case finding and screening groups will be compared.GPs will be asked to rate the acceptability of the GPCOG and the Management Guidelines. Descriptive data will be reported.Within the Intervention group, the patient outcomes for the group with memory complaints or identified by the GP as having possible or probable dementia (case finding group) will be compared with outcomes for the group without memory complaints or identified memory problems (screening group). Acceptability of the process and satisfaction with care will be particularly examined, both from a quantitative and a qualitative point of view. The performance of the GPCOG in the case finding and screening groups will be compared. In particular positive predictive value, negative predictive value and misclassification rates will be compared. GP audits will be examined to determine how many patients in each group would have a missed diagnosis of dementia if the GPCOG had not been administered.The GPCOG will be compared with the DSM diagnosis derived from the CAMCOG as a 'gold standard', and sensitivity, specificity, positive predictive value, negative predictive value and misclassification rate will be calculated. ROC curve analysis will be employed to examine the discrimination ability of the GPCOG test (i.e. ability to detect dementia) relative to MMSE. This is important as the MMSE is now commonly used in General Practice. GPCOG test-re-test and inter-rater reliability (between the nurse and the GP) will be calculated, using the kappa coefficient and intra-class correlation coefficient.In the case of data missing from the study questionnaires, the questionnaires will be handled as suggested in the literature for that questionnaire. This varies from questionnaire to questionnaire.The project is being overseen by a group consisting of the chief investigators, associate investigators and the project manager. This group will meet two to three times a year by teleconference and face to face. Day to day management will be undertaken by monthly project officer teleconferences.Ethics approval was sought and granted initially from the Newcastle University Human Research Ethics Committee , and following this, from the appropriate Ethics Committees at each site.CDP and HB have sat on advisory boards for Pfizer, Novartis, Janssen and Lundbeck, and been speakers sponsored by Pfizer, Novartis (HB only) and Janssen (HB only). HB has been an investigator on projects funded by Pfizer, Novartis, Janssen, Lundbeck, Lilly and Sanofi, and acted as a consultant for Merck and Baxter. Other authors have no competing interests to declare.CDP conceived and developed this study, drafted the manuscript and has overall management of the project. HB assisted in study design and manages operations at the Sydney site. NS assisted in study design, and manages operations at the Adelaide site. JG assisted in study design, and manages operations at the Melbourne site. JM assisted in study design. PD assisted in study design, and manages operations at the Bendigo site. PM assisted in study design and drafted the manuscript. NP developed the educational intervention, assisted in study design. GH developed the educational intervention, assisted in study design. SG assisted in study design, provided project management and drafted the manuscript. BP collected data and provided project management. KM assisted in study design, collates data, will assist with statistical analysis and drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/13/12/prepub


The high prevalence of pain reported in many epidemiological studies, and the degree to which this prevalence reflects severe pain is under discussion in the literature. The aim of the present study was to evaluate use of the simple neck pain questions commonly included in large epidemiological survey studies with respect to aspects of health. We investigated if and how an increase in number of days with pain is associated with reduction in health outcomes.A cohort of university students (baseline age 19–25 years) were recruited in 2002 and followed annually for 4 years. The baseline response rate was 69% which resulted in 1200 respondents . Participants were asked about present and past pain and perceptions of their general health, sleep disturbance, stress and energy levels, and general performance. The data were analyzed using a mixed model for repeated measurements and a random intercept logistic model.When reporting present pain, participants also reported lower prevalence of very good health, higher stress and sleep disturbance scores and lower energy score. Among those with current neck pain, additional questions characterizing the pain such as duration (categorized), additional pain sites and decreased general performance were associated with lower probability of very good health and higher amounts of sleep disturbance. Knowing about the presence or not of pain explains more of the variation in health between individuals, than within individuals.This study of young university students has demonstrated that simple neck pain survey questions capture features of pain that affect aspects of health such as perceived general health, sleep disturbance, mood in terms of stress and energy. Simple pain questions are more useful for group descriptions than for describing or following pain in an individual. In epidemiological cohort or surveillance studies, where musculoskeletal pain is only one health aspect among many others investigated, the multidimensional aspects of pain have to be captured in only a few variables. Therefore, multi-item instruments for pain assessment are not suitable for the epidemiological survey setting. In the present paper, we term such assessments ‘simple’, as they only capture simple characteristics of pain, such as its presence or duration -8, and aAssessment of pain is difficult as pain is subjective, multidimensional, and variable in its manifestation and varies over time ,10. ChroDiscussions concerning the high prevalence of pain revealed in many epidemiological studies -18 led uOne important property when evaluating questionnaire-based instruments is its validity, i.e., that it measures what it intended to measure or assess. When evaluating the validity of simple pain questions the focus is here not to question if they assess pain or not, but if the questions assess pain that is of enough severity to be of public health interest. Pain per se is a warning signal we need, but when pain becomes a dysfunctional symptom  it is something we want to prevent and cure. In epidemiological studies it may therefore be argued that it is most important to identify pain that affects the life of the individual . HoweverEvaluation studies of the Nordic Questionnaire (NQ) are of interest here as they include simple pain questions similar to those investigated in the present paper. Results from studies based on the NQ mostly concern validity with respect to diagnosis, showing mostly that the NQ has high sensitivity and low specificity -22, althThe aim of the present study was to evaluate simple pain assessments in relation to the impact on aspects of health  and decreased general performance; and whether an increased number of days with pain or additional pain sites are associated with reduced health and decreased general performance.A cohort of university students (baseline age 19–25 years), enrolled in medical and information technology (IT)-related studies, were recruited in 2002 to respond to Internet-based questionnaires providing baseline and further data from four annual follow-ups Figure All subjects received written information concerning the study and their right to refuse to participate. The project was approved by the Regional Ethical Review Board at the University of Gothenburg, Gothenburg, Sweden. A more extensive description of the study is presented elsewhere .In the present paper neck pain is defined as the two areas ‘neck’ and ‘upper back’ in Figure In the present paper, questions were asked about the presence and duration of neck pain and whether the pain decreased the individual’s general performance. The phrasing of the questions, and their possible response values were:Do you at present have aches/pain in the upper part of your back/neck? 1) Number of days with current aches/pain 2) Have you had decreased general performance due to ache/pain in muscles or joints over the past 30 days? 3) Note that the question concerning decreased general performance was not phrased with reference to neck pain, but only to pain in muscles and joints in general. Question a) and b) were also asked for other pain sites (lower back or arms/hands).perceived general health[sleep disturbance and mood (stress and energy). The variable general health was dichotomized according to cutoff points indicated in the results of logistic regressions for ordinal outcomes (cumulative logit). The definition of the dichotomized variable very good health is presented in Table Selected outcome variables were al health,27, sleesleep disturbance variable [sleep disturbance the mean score of the included items was calculated and sleep disturbance was then standardized to a 0–10 scale.Rasch analysis was performed on the items in the variable  to checkvariable . The sumstress and energy, are related, to some extent, to emotional wellbeing [present mood was examined, while in this study, mood over the past 7 days was the focus. For the variables stress and energy the mean score of the included items was calculated, according to original use of the scores [The two dimensions of mood, ellbeing . The mooe scores ,32.sleep disturbance, stress, and energy were constructed by combining the separate items into variables and were treated as numerical in the analysis. The decision to treat these three variables as numerical is based on results from Rasch analysis. When data fit the Rasch model, a linear transformation of the raw ordinal score is obtained, which converts the ordinal variables into a one-dimensional assessment on the logit scales [As explained above the variables t scales .present pain duration described in terms of the median (md) value for the number of days with pain, and the 1st and 3rd quartiles (Q1 and Q3), together with the mean number of days indicated skewness: women: mean = 652, md = 60, Q1 = 5, and Q3 = 730, men: mean = 631, md = 135, Q1 = 4, and Q3 = 912. A descriptive graph is presented for the baseline data for duration to show the distribution of the pain duration in more detail than is later used in the analysis. The duration of pain was, in the analysis, categorized into the four categories: 1–7 days, 8–90 days, 91–365 days and more than 365 days. This choice of categories was based both on commonly used cut-offs for duration of pain and on the statistically-based requirement of enough individuals in each group.The baseline distribution of current pain, individuals with and without current pain.Descriptive data and descriptive baseline analysis were performed presenting results for the health outcomes between the two groups formed by the variable sleep disturbance, stress, and energy. In these analyses men and women were not separately analyzed as the baseline results showed very similar results, but were included as an explanatory variable in the regression models when relevant. The models were constructed follows: the gender variable was included if p ≤ 0.05. The interaction between gender and the explanatory variable of interest was also tested, but nowhere found statistically significant.The pain assessments and the outcomes were both collected on five occasions: t = 0, 1, 2, 3, 4. Hence, the data used in the regression analyses are derived from individuals followed over 4 years. This strengthens the analyses, as comparing more homogenous units, such as examining changes in individuals, reduces the chance that there are unattended confounding factors influencing the results. Even more important in this study, this analysis will give information on within-individual difference in health outcomes when reporting and not reporting current pain. In order to handle the longitudinal design, mixed models  were used to analyze the relationships between pain assessment and the outcomes Both the sleep disturbance score and the mood scores are each based on several items that were ordinal, but as described above Rasch analysis was performed and the resulting scores could then be analyzed using parametric methods.very good health. The percentages and numbers of respondents in each original response category for the separate items and separate ordinal categories included in very good health and sleep disturbance are presented in Table The variable of general health was originally an ordinal variable, but dichotomized into a binary variable All analyses were performed using the statistical package SAS, version 9.2 .very good health a random intercept logistic regression was used for the longitudinal design .For the outcome In the Additional file present pain in upper back/neck was 27% among women and 11% among men. The baseline prevalence for neck pain in combination with at least one more pain site (lower back or arms/hands) was 15% for women and 5% for men and the prevalence of pain in all three sites (lower back and arms/hands) was 5% for women and 2% for men.The baseline prevalence of Both among men and women a large part of the neck pain represented a short duration of only 1–2 days  and duration of 3–7 days   within-subject and between-subject variations were achieved from the longitudinal regression analyses. The within-subject variation, regarding the health outcomes, was in all analyses larger than the between-subject variation, except for all analyses of sleep disturbance where the within-subject variation was smaller than the between-subject variation , and also because the NQ was never intended to measure clinical diagnoses, as mentioned previously. Therefore, validation of pain assessments should include comparisons with other measures of the intended characteristics of pain. According to the work of the Task Force on Neck Pain and Its Associated Disorders, diagnostic procedures for non-traumatic neck pain have not been proven valid or useful . They coAnother qualitative requirement of pain assessment instruments is repeatability. For the NQ, repeatability was found to be good  when the time interval between questionnaires was about 1 week .decreased general performance may be too narrow a concept when looking at how pain affects life, a question directed at the broader effects of pain on life may increase the validity of pain assessments even further.Assessing pain as the presence of pain in combination with its effect on performance increased the validity of some of our outcomes. However, because the wording The reported pain in the present young age group may be less severe than, and may not affect life in the same way as, reported pain in older age groups. This could possibly explain the less clear differences in the outcomes between pain and no pain, and may point to the necessity of an additional question, as discussed previously. A ‘yes’ from a not so affected individual is not possible to distinguish from a ‘yes’ from a more affected individual, which may explain the high prevalence of pain in such a young age group.Epidemiological studies regarding pain outcomes could benefit from more clearly specified definitions of those aspects of pain that are of most interest and importance for the individual, workplace or society.There is a risk of bias due to homogeneity of answers when assessments are self-reported; for example, when a respondent gives a negative answer to one health item, there is a tendency for him or her to also report negatively about other health aspects. This type of bias could be decreased to some extent if an outcome is related both to pain assessments made at the same time as the outcome, and to assessments from the previous year, as done in the present study.The results of this study should be generalized with caution, because the respondents, being young university students enrolled in academic studies, form a group with quite specific characteristics.At the time of the study, it was not possible to include figures in the web-based questionnaire and hence, only words were used to define the location upper back or neck. This could endanger the validity of the pain location ‘upper back/neck’ referred to in the questionnaire. To validate the pain questions regarding pain location medical examinations were conducted on a sub-sample of 42 participants from the baseline of the university cohort. These medical examinations included pain drawings from which presence of neck pain could be defined and compared with the answers from the questionnaire. From these drawings, the agreement between neck pain, according to Task Force on Neck Pain and Its Associated Disorders, and pain in the upper back and neck  of a possible difference in sleep disturbance, between those reporting and those not reporting sleep disturbance.This study of young university students has demonstrated that simple neck pain survey questions capture features of pain that affect aspects of health such as perceived general health, sleep disturbance, mood in terms of stress and energy. However, simple pain questions are mainly useful for group descriptions rather than for describing or following pain in an individual, as knowing about the presence or not of pain explains more of the variation in health between individuals, than within individuals.The authors declare that they have no competing interests.A.E. performed the statistical analysis, interpreted the results, and wrote the main part of the text. M.H. was in charge of the design and acquisition of data, made substantial intellectual contributions to the study, and was involved in drafting the manuscript and revising it critically. Both authors have read and approved the final manuscript.Appendix. The parameter estimates presented in Table A, were used to calculate the results in Table Click here for file


This paper explores the decline in child marriage and changes in its effect on reproductive outcomes of Bangladeshi women, using the 2007 Bangladesh Demographic and Health Survey data. Chi-square tests, negative binomial Poisson regression and binary logistic regression were performed in analyzing the data. Overall, 82% of women aged 20-49 years were married-off before 18 years of age, and 63% of the marriages took place before 16 years of age. The incidence of child marriage was significantly less among the young women aged 20-24 years compared to their older counterparts. Among others, women's education appeared as the most significant single determinant of child marriage as well as decline in child marriage. Findings revealed that, after being adjusted for sociodemographic factors, child marriage compared to adult marriage appeared to be significantly associated with lower age at first birth , higher fertility , increased risk of child mortality , decreased risk of contraceptive-use before any childbirths , higher risk of giving three or more childbirth , elevated risk of unplanned pregnancies , increased risk of pregnancy termination , and higher risk of the use of any current contraceptive method . Increased enforcement of existing policies is crucial for the prevention of child marriage. Special programmes should be undertaken to keep girls in school for longer period to raise the age of females at first marriage in Bangladesh and thereby reduce the adverse reproductive outcomes. Marriage marks the onset of a socially-acceptable institution in a society where offspring procreation occurs within marital union and illegitimate childbirths are rare. It is an important and memorable episode of life for men as well as women. Age at first marriage is more important for young people as it marks the beginning of transition from adolescence to adulthood. Timing of the first marriage or union is an important dimension of women's reproductive behaviour, with far-reaching consequences, particularly for their reproductive health and social status . Thus, aChild marriage (before the age of 18 years) and marriage at very young age (before the age of 16 years) are a reality for many women . The praMarriage at a very young age has grave social, psychological and health consequences for both young women and their children. Child marriage is not only recognized as a human rights violation, it is also a barrier to individual and social development. Considerable evidence shows that the negative consequences of child marriage are numerous, especially harmful for girls, their children, and their communities . PreviouFurthermore, girls already in school are often forced to terminate their education when they marry early . LimitedIn Bangladesh, as in many other countries of South Asia, marriage is nearly universal and women marry at a very young age . BangladWe hypothesize that education has a significantly negative effect on child marriage. We also hypothesize that the effect of education is largely independent of current age of women, type of place of residence, religion, region of residence, and wealth index. Furthermore, we hypothesize that women of younger generations are less likely to be married as a child compared to those of the older generations due to increased level of education over time. In addition to these, we hypothesize that child marriage is significantly associated with lower age at first birth, higher fertility and child mortality, lower use of any contraceptive method before any childbirth, increased risk of unintended pregnancy, and pregnancy termination.The study used data from the 2007 BDHS—the nationally-representative survey that gathered information from 10,996 ever-married women aged 15-49 years and 3,771 men aged 15-54 years from 10,400 households. The survey used a multistage cluster sample based on the 2001 Bangladesh Census. The survey obtained detailed information on fertility levels, marriage, fertility preferences, awareness, and use of family-planning methods, breastfeeding practices, nutritional status of women and young children, childhood mortality, maternal and child health, knowledge and attitudes regarding HIV/AIDS, etc. The survey was conducted under the authority of the National Institute for Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. The details of the survey have been described in the survey report .The study dealt with the weighted sample of 9,572 ever-married women aged 20-49 years. The sample was made weighted by the corresponding weighting factor provided for each of the sample women in the SPSS raw data. The ever-married female adolescents aged 15-19 years were excluded from analyses as almost half of the female adolescents remained unmarried during the survey and their inclusion may bias the findings.For deepening our understanding of the extent to which child marriage has declined over time and of the factors causing child marriage and marriage at very young age, the first part of this study dealt with two dependent variables: marriage at very young age (marriage before 16 years of age) and child marriage (marriage before 18 years of age). In the second part, we assessed the effect of child marriage on the adverse outcomes of various reproductive behaviours of women. In this part, the demographic and fertility-related dependent variables included for analyses are: age at first birth, number of children ever born, number of children who died, use of family-planning (FP) method before any childbirth, childbirth within one year of marriage, three or more childbirths, whether the most recent pregnancy was intended or unintended, ever had terminated pregnancy, and current use of any FP method.To assess the net effect of marriage before 16 years of age and marriage before 18 years of age, six vital factors were included as the independent variables: current age of the women, women's education, current place of residence, geographical region, religion, and wealth index. Year of marriage was considered an independent variable in bivariate analysis but was not included in multivariate analyses to avoid multicollinearity with current age of women. Along with these variables, age at first marriage was included as an independent variable to examine the effect of child marriage on the reproductive behaviours of women. The definitions and coding of the dependent and the independent variables considered for analyses are presented in Table 1.Both bivariate and multivariate statistical analyses were employed in this study. The associations of very young marriage and child marriage with sociodemographic characteristics were assessed by chi-square tests, with significance for all analyses set at p<0·05. This was followed by logistic regression to assess the net effect of the covariates on the outcome variables. Negative binomial Poisson regression was employed to estimate the incidence of relative risk (IRR) for child marriage on fertility outcomes (for count data), such as age at first birth, number of children ever born, and number of children who died. Besides, a series of binary logistic regression models were constructed to assess the net effect of child marriage on the reproductive behaviours of women, after confounding with other selected independent variables. The results of the negative binomial Poisson regression analyses are presented by regression coefficients, and IRR with 95% Wald confidence interval (WCI) and those for logistic regression analyses are presented by regression coefficients and odds ratios (OR) with 95% confidence interval (CI). The statistical analyses applied in this study were performed by SPSS (version 17).Current age of women, after being adjusted for other covariates, did not show any apparent pattern of decline in marriage at very young age and child marriage. For instance, compared to women aged 20-24 years, the women aged 45-49 years were two times likely to be married-off at very young age. However, the difference in the likelihood of being married at very young age between women aged 20-24 to 40-44 years was not found to be significant. Women aged 45-49 years compared to the young women aged 20-24 years were almost two times likely and those aged 25-29 years were also likely to be married-off as child by the factor 1.64. The difference in the likelihood of being married-off as child between women aged 20-24 years and 30-34 to 40-44 years was not found to be significant. Overall, the child marriage has significantly declined in women of younger generation than those aged 45-49 years.Women's education showed a significantly negative relationship with the timing of marriage when other sociodemographic covariates were kept constant. For instance, women with primary, secondary and higher education, compared to those with no formal education, were respectively 24%, 72%, and 94% less likely to be married at very young age. Almost a similar pattern of decline in child marriage was observed for this variable. Compared to the urban women, the rural women were more likely to be married-off at very young age and be married as child by factor 1.21 and 1.35 respectively. The women of Chittagong and Sylhet division were less likely and those of Khulna and Rajshahi division were more likely to be married at very young age compared to those of Barisal division. Besides, the women of Chittagong, Sylhet and Dhaka division were less likely to get married before 18 years of age compared to women of Barisal division.The likelihood of being married-off at very young age and child marriage was 52% and 59% less among the non-Muslim women than their Muslim peers. The wealth quintiles showed consistently a negative association with marriage at very young age; child marriage decreased significantly among women from richer and the richest families. The current age and women's education produced 13 interaction terms, in which two and four terms appeared to be significant for marriage at very young age and child marriage respectively. The significant interaction terms as shown in The multivariate logistic regression analysis, adjusted for relevant socioeconomic and demographic factors, showed that the women married as child were significantly (p<0.001) less likely to report using any contraceptive method  before any childbirth than those who were married-off as adult. Childbirth within one year of marriage was significantly lesser by the factor 0.67  among the women who got married as child than women who were married-off as adult. The women married as child were significantly more likely to have three or more children , increased risk of unintended recent pregnancy (OR=1.21 95% CI=1.02-1.45), boosted risk of pregnancy termination , and elevated risk of current contraceptive-use  compared to women who got married as adult.Marriage is an event of great social and cultural importance to women and men in most societies where childbirth is not socially acceptable without marital bond. This study aimed at examining the decline in child marriage in Bangladesh and investigating the effect of child marriage on various reproductive behaviours. The findings of the study reveal that the practice of child marriage is very common in Bangladesh. Overall, the prevalence of child marriage was 82%, and the mean age at first marriage was 15.3 years, indicating that Bangladeshi women were married-off 2.7 years earlier than the legal age at first marriage for females. These statistics suggest that most female marriages still take place before the legal age at first marriage. Findings suggest that current age, women's education, place of residence, socioeconomic status, religion, and regions are important determinants of child marriage in Bangladesh.The reported prevalence of child marriage reveals that Bangladeshi girls are more vulnerable to child marriage in South Asian context as well as in the world. For instance, a recent study conducted on Indian women reported that 45% of women aged 20-24 years were married-off before 18 years of age  whereas Although the bivariate analyses showed apparent pattern of decline in child marriage and marriage at very young age by age cohort of women, the multivariate analyses yielded curvilinear pattern of the likelihood of these two outcome variables. Analyses by year of marriage and age cohort of women reflect that Bangladeshi women are in transition with regard to timing of marriage. For instance, the youngest women were more likely to be married as adult opposed to their older counterparts. This may be partly attributed to the higher educational attainment of younger women compared to their older counterparts as well as socioeconomic transition in the country. This finding is consistent with studies conducted on ethnic tribal women of Bangladesh  and elseWomen's education is the most significant single determinant of child marriage in Bangladesh. Typically, higher education of the respondents is likely to be associated with lower probability of early marriage . ConsistThe patterns of covariates of marital timing among the women under study reflect a society in evolution . Place oMarriage at very young age and child marriage varied significantly among the administrative regions of the country. It is likely that discernable culture and regional socioeconomic variations might have impact on the timing of marriage. The regional socioeconomic development disparities are bound to affect the timing of marriage . Thus, wThe present wealth index of the women does not actually reflect their parental socioeconomic status at the time of their marriage. However, the prevailing culture in Bangladesh reveals that parents, guardians as well as the women and men look for grooms and brides of similar socioeconomic status. Thus, the wealth index is an indirect indicator of socioeconomic status of women, their parents as well as their in-laws’ families. Our findings revealed a significantly negative association between wealth index and marriage at very young age. It is likely that the women with a better economic status are likely to be provided by their parents with more alternatives to early marriage, such as higher education and occupational attainment, resulting in lower likelihood of child marriage among them compared to their poor counterparts. This is supported by the interaction terms for age and education. The significant interaction terms suggest that women's higher education than current age of women is a much more important predictor in reducing child marriage.In societies where marriage is the precursor of socially-acceptable childbirth, childbearing begins soon after marriage. Early marriage is associated with early childbearing in most cases, particularly in the developing world where the main purpose of marriage is to have children . The assConsistent with many studies -22, our The higher likelihood of child mortality among women married at childhood may be attributed not only to biological and physical maturity but this is also partly attributed to longer duration of marital life. Young maternal age is probably a marker for one or more other maternal risk factor(s) associated with adverse birth outcomes rather than only an indication of incomplete maternal growth . The obsThe lower likelihood of childbearing within one year of marriage among women married as child compared to their adult peers may be partly attributed to biological and physical immaturity among them. Besides, women married at later ages do hurry to have childbirth as they already have passed substantial time for offspring procreation. Furthermore, the higher risk of unplanned pregnancies among the women married as child may be attributed to failure in proper planning of the timing of childbearing and lower use-rate of family planning methods compared to their adult peers. Studies reveal that transition to parenthood at early age is an important and stressful life-event that involves multiple risk factors, such as psychological, marital and economic issues for new mothers -34, partThe study has several limitations. First, it dealt with self-reported data that may have error in reporting the sensitive information, like pregnancy termination, although menstrual regulation, which is a type of voluntary pregnancy termination, is legal in Bangladesh whereas induced abortion is still illegal in the country unless it is necessary to save mother's life. It is likely that women often hide the information of induced abortion to escape from social criticism. Second, many variables have been left, such as parental socioeconomic status, working status at the time of marriage, consanguine marriage, etc. These variables were not included in the analyses due to paucity of data, which are important factors in analyzing child marriage. Third, in Bangladesh, as in many other developing countries, there might have error in reporting the respondents’ age, age at marriage, and age at first birth, etc. Many women of reproductive age in Bangladesh prefer hiding their actual age to prove them young. This is due to the fact that registration of age at birth and even age at marriage is not properly followed and maintained. Despite these limitations, the strength of this study is that it dealt with the nationally-representative standard DHS data mostly used from public-health and demographic perspectives.The study shows that child marriage is still common in Bangladesh. The pervasiveness of child marriage and its association with higher fertility and poor control of fertility—factors linked to numerous poor maternal and child health outcomes—urges the crucial need for maintaining proper marriage registration and increased family-planning interventions tailored to married adolescents. Poverty and lower education are two crucial factors for early marriage as well as adverse reproductive outcomes. Thus, the findings of the study further suggest that reducing the prevalence of poverty and the need to remain girls in school for a longer period are necessary not only to raise the age at first marriage but also to promote the individual development and their potential contribution to society for overall development. Programmes should be undertaken aiming to inform teenage girls about the adverse outcomes of early marriage and early motherhood through formal and informal education. Parents should be advised to avail of the opportunity of female stipend programme in Bangladesh for their girls to be more educated. Findings of the study suggest that education alone cannot reduce child marriage in Bangladesh as other socioeconomic factors have causal relationship with very young age at marriage. To reduce child marriage and teenage motherhood, the marriage act may be reviewed, and the legal age at marriage may be set at 19 years for females as the country has been passing through a transition period in its economic development. Further, door-step delivery of services for modern contraceptive methods may also reduce teenage motherhood. Healthcare facilities should be made available among the poor and in remote areas for better health of both mother and child in Bangladesh.