Several studies have been carried out in order to investigate the effect of ankle bracing on ankle joint function and performance. However, no study so far has examined the role of skin-brace interface pressure in neuromuscular control. The aim of this study was to investigate the effect of different skin-ankle brace interface pressures on quiet single limb balance and the electromyographic (EMG) activation sequence of four lower limb muscles.Thirty three male physical education students who volunteered to take part in the study were measured under three ankle brace conditions: i) without brace, ii) with brace and 30 kPa application pressure and iii) with brace and 60 kPa application pressure. Single limb balance  was assessed on the dominant lower limb, with open and closed eyes, on a force platform, simultaneously with the EMG recording of four lower lower limb muscles'  activation onset.The results showed that overall balance  was not significantly affected in any of the three ankle brace conditions. However, the anteroposterior centre of pressure excursion and centre of pressure excursion velocity were significantly increased with the application of ankle brace, both with 30 and 60 kPa application pressures. Furthermore, it was found that single limb balance was significantly worse with closed eyes compared to open eyes. EMG measurements showed that the sequence of lower limb activation onset was not affected in any of the three ankle brace application conditions. The results of this study showed that the application of an ankle brace with two different skin-brace interface pressures had no effect on overall single limb balance and the sequence of lower limb muscle activation.These findings suggest that peripheral joint receptors are either not adequately stimulated by the brace application and therefore are not able to alter the balance control strategy of the CNS, or that they play a less important role in the control of single limb balance. Further research is needed in this area with more dynamic and functional measurements, before the safe use of ankle bracing can be widely recommended. Ankle bracing comprises one of the most common prophylactic measures used during competition by sports participants, in order to prevent lateral ankle sprains. Several experimental studies have been carried out in order to investigate the effect of ankle bracing on athletic performance and other parameters related to function. However, the effect of ankle bracing on balance and postural control has been investigated by a limited number of studies that have demonstrated both positive and negative findings. Bennell & Goldie , showed Friden et al. , who alsAccording to all these studies, controversy seems to exist as to the effect of ankle bracing on postural control due to methodological differences of balance assessment, type of brace used and technique application. Furthermore, a limited number of studies have been carried out so far to investigate the effect of ankle bracing on EMG activation time of lower limb muscles. Lower limb activation sequence during standing balance is an important parameter which is related to ankle joint neuromuscular function. Specifically, it was considered important in this study to investigate whether the application of an ankle brace with different pressures affects only the activation sequence of four muscles, and not the overall EMG activity during the 5 sec trial, either due to the stimulation of the skin receptors or to the restriction of joint motion. In a previous study, Roller et al  investigTherefore, the purpose of this study was to investigate the effect of different skin-brace interface application pressures on quiet single-limb static balance and whether the balance maintenance strategies during a single limb stance, can be altered with the application of a specific widely used type of ankle brace the sequence of lower limb muscle activation during balance.Thirty-three male physical education students, volunteered to take part in the study. The experimental investigation with human subjects reported in the manuscript was performed with informed consent and followed all the guidelines for experimental investigation with human subjects required by the institutional review board and the ethics committee with which the principal investigators are affiliated. Subjects had no history of severe ankle sprains and joint instability and did not ever make use of an ankle brace or any other type of ankle support. Eligible subjects that were entered to the study underwent anthropometric measurements Table , and werThe laced-up McDavid ankle brace  was used for the measurements in the study.Single limb balance was assessed using the MatSCAN force platform  which displayed the average centre of pressure (COP) excursion and centre of pressure excursion velocity in the anteroposterior and mediolateral directions. All measurements described in the study were performed without shoes. All measurements, in all subjects, were performed firstly without brace, secondly with brace and 30 kpa pressure and thirdly with brace and 60 kPa pressure. For this reason an order effect was ruled out, since it was the same for all subjects. The Tekscan mat calibration was done using a Uniform Bladder System, described by Nicolopoulos .σr), described by Riley et al. [A combined stability parameter , for 5 seconds as quietly as possible, staring at a 3 cm spot fixed one meter on the wall in front of them Figure . BalanceInterface pressure was measured with the 9811 F-Socket  sensor which was applied in the anterior aspect of the ankle underlying the brace laces. The F-Socket was calibrated using a sphygmomanometer around the ankle joint up to the point where the desired pressures (30 & 60 kPa) were reached.Pressure was applied by tightening the laces until the predetermined amount of pressure (30 & 60 kPa) was reached Figure . The twoThe effect of the McDavid ankle brace on the sequence of lower limb EMG muscle activation was measured simultaneously with the balance measurements. Surface Electromyography (EMG) was used to determine the activation time of the gastrocnemius, peroneous longus, rectus femoris and biceps femoris muscles, using a pair of bipolar surface silver chloride electrodes. These muscles were selected because according to the literature they have been used by previous studies for the EMG measurement during single limb balance and are of significant importance in the control strategy of standing balance ,17.The Biopac MP100 System  was used to record and analyse the EMG signal. After the skin was shaved and degreased with 70% alcoholic solution, electrodes were attached to the skin parallel to the muscle fibres, on the most prominent point of the muscles -24, duriStatistical analysis was performed with the SPSS version 11.5. In order to analyze differences for balance and EMG measurements between the three ankle brace conditions, as well as for open and closed eyes and the eyes by brace interactions, the two way ANOVA was used. The Bonferonni test was applied for post-hoc comparisons in order to calculate the range of differences and the mean differences, together with the 95% confidence interval. The paired t-test and the mixed effects ANOVA model on the other hand were used to calculate differences for the stability parameter. Since balance was measured twice on the same individual, once with open and another time with closed eyes, a paired t-test was used to calculate the difference in stability parameter between open and closed eyes.Similarly, as the balance for the 3 ankle brace conditions was measured three times on the same individual, a mixed effects ANOVA model was used to calculate the differences in the stability parameter between the three brace conditions taking also into account the correlation between adjacent observations. For the assessing the statistical significance of a hypothesis a common significance level of 5% was assumed.Mean values for the centre of pressure excursion (mm) and centre of pressure excursion velocity (mm/sec), in the mediolateral and anteroposterior direction are displayed in Tables In the anteroposterior direction however, significant differences were found between the condition with 30 kPa brace application and the condition without brace  and between the condition with 60 kPa brace application and the condition without brace . Specifically, ankle brace application resulted in a deterioration of the anteroposterior COP excursion and excursion velocity, both with open and closed eyes , mediolateral  and the total  stability parameters. Lastly, significant differences were found in the total stability parameter between open and closed eyes . Table Analysis of variance showed that there were no significant differences in the activation time of the peroneus longus , gastrocnemius , rectus femoris  and biceps femoris , between the three ankle brace application conditions. Furthermore, no significant differences in EMG activation time were found in single limb balance between open and closed eyes for the peroneus longus, gastrocnemius and rectus femoris muscles. However, significantly faster activation of the biceps femoris muscle was detected with open eyes as compared to closed eyes, in all three brace conditions. Mean EMG activation time values are displayed in Table σr', was not positively or adversely affected by the two different brace application pressures. This finding is in agreement with previous studies, which showed that ankle bracing had no effect on postural control, without however, referring to the pressure of brace application [σApr) and the anteroposterior (σLatr) stability parameters, as well as the total stability parameter (σr), were not significantly affected, it may be concluded that overall, the application of the two different ankle brace application pressures, had no positive or negative effect on quiet single limb balance. This is also supported by Riley et al. [To the best of our knowledge, this study is the first to investigate the effects of ankle brace application pressures on postural control and electromyographic activation sequence of lower limb muscles. In a recent study, Papadopoulos et al. , examinelication ,6. It walication , and Paplication , who alslication , was advy et al. , who stay et al. ,28-31 any et al. .The results of the electromyographic measurements showed that the sequence of lower limb muscle activation onset was not altered by the application of two different ankle brace application pressures. This finding cannot be compared with previous studies since this is the only study that has investigated the effect of ankle bracing on the EMG activity of lower limb muscles and, as mentioned above, the only that has examined the effect of different brace application pressures. However, useful information that arises is that different ankle brace application pressures do not change the ankle strategy of balance control, which is the one that dominates during balance of young healthy subjects ,14,9,33.The findings of this study showed that regardless of application pressure, ankle bracing had no adverse effect in single limb balance or EMG activation sequence. This finding is limited to the specific type of ankle brace that was used in the study and cannot be generalized to other types of ankle support. However, in another study by Papadopoulos et al. , it was The authors declare that they have no competing interests.ESP, CN, and AB participated in the design of the study, data acquisition and analysis and writing of this manuscript. GV, participated in the analysis and writing of this paper. SAP and SA participated in the analysis and also in revising critically the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Sports and arts based services for children have positive impacts on their mental and physical health. The charity sector provides such services, often set up in response to local communities expressing a need. The present study maps resilience promoting services provided by children's charities in England. Specifically, the prominence of sports and arts activities, and types of mental health provisions including telephone help-lines, are investigated.The study was a cross-sectional web-based survey of chief executives, senior mangers, directors and chairs of charities providing services for children under the age of 16. The aims, objectives and activities of participating children's charities and those providing mental health services were described overall. In total 167 chief executives, senior managers, directors and chairs of charities in England agreed to complete the survey. From our sample of charities, arts activities were the most frequently provided services , followed by counselling  and sports activities . Only 13% (22/167) of charities expected their work to contribute to the health legacy of the 2012 London Olympics. Telephone help lines were provided by 16% of the charities that promote mental health.Counselling and arts activities were relatively common. Sports activities were limited despite the evidence base that sport and physical activity are effective interventions for well-being and health gain. Few of the charities we surveyed expected a health legacy from the 2012 London Olympics. Children's physical and mental health is adversely affected by social difficulties, low educational achievement, family mental illness, poor parenting, poverty and other traumatic life events -3. AmongResearch indicates that getting involved in sport is an effective treatment for and an important part of preventive strategies for obesity, diabetes, heart disease, and other health conditions -14. ArtsA number of sectors take responsibility for health and well-being. These actions are not restricted to public funded services, indeed communities are increasingly encouraged to take responsible actions to protect and preserve health. Statutory health services usually provide targeted interventions for specific health conditions with a shifting emphasis now to health promotion and prevention . On the From a search of established charity websites (e.g. Guidestar UK and the Charity Commission) we confirmed the correct names and contact addresses for the official contacts of 500 charities that provide services for children under the age of 16. The charity commission's database has a record of all registered charities, and maintains public records about them. It also codes their aims and objectives on pre-determined categories against which their aims and objectives are classified and against which they are registered as charities by the charities commission.We sent emails to each charity's official contact person and requested the name, telephone number and e-mail address of their chief executive, director, manager or chair. Following this, we undertook a web-based survey between April and August 2008 of chief executives, directors, managers or chairs. A first e-mail asked participants to access and complete an on-line survey; after a three month period a second reminder was sent to charities not responding to the first round. A second non-response was followed by telephone follow up and interview.Initially, we reviewed the aims and objectives of charities as set out on the Charity Commission's database. These aims and objectives clustered into 20 categories used in the Charity Commission and Guidestar UK websites. For each of the 20 categories of aims and objectives, we asked a stem question, followed by additional questions about specific activities which are considered key areas of provision by National Children's Bureau, the Every Child Matters Agenda; the Sure Start Scotland mapping and evaluation exercise and Children's Services Mapping (CSM). Thus, endorsing any of the 20 stem question triggered additional detailed questions about activities of relevance to that particular aim and objective. Overall there were 133 additional questions. For example, for charities promoting mental health we asked about the provision of mental health promoting telephone help-lines. We collated these responses to estimate how many charities overall provide sports activities and arts activities . A favourable ethical opinion was given by Queen Mary research ethics committee.In total, we received complete information from 167 charities  which agreed to complete the survey; this represents a third of the sample charities that provide services for children under 16 in England. This response rate was not unreasonable for a web-based survey . All nonTable Table The findings show a significant emphasis on counselling services and arts projects, but less on sport. Despite the existing evidence base on the benefits of sports activities, only a fifth of the overall sample offered this service.Children's involvement in the 2012 London Olympics is supposed to be significant because they will take part as participants, spectators and organisers. Sir Steve Redgrave, regarded as one of the greatest Olympians, was appointed as the government's 2012 Olympic champions to inspire young people's participation. It is expected that children's levels of activity and involvement in sport will increase with demonstrable health benefits. Future surveys of young people in East London and nationally should show improvements in self-reported resilience and wellbeing. This legacy should ideally be demonstrable for all cultural groups, if the Olympic vision of transforming the nation's attitude to sport and intercultural communications is to be met. The charity sector could significantly contribute to local promotion of sport and the health legacy, but commissioners need to engage with the charity sector more actively. This survey provides useful baseline data but needs to be supplemented by additional surveys of young people. A future surveys are essential to measure and map the health legacy of the 2012 London Olympics. For example, the impacts may emerge from regeneration, new housing and better transport, new leisure facilities, as well as greater participation in sport. The different effects will have to be disentangled.The limitations of this study should be mentioned. Our survey may have been too selective, with less participation by charities providing more sports, or other social interventions. However, we did not recruit by reference to any particular form of charity other than those providing services for children. We could not demonstrate any differences in the published aims and objectives of charities that participated in this study and those that chose not to take part. As the survey originated in a psychiatry research group, albeit an environmental and cultural psychiatry research group, it may have selectively attracted charities that provide mental health services. Potential research participants might have assumed that we were interested only in mental health providers. However, this is not reflected in the reasons for non-participation, with only 4% suggesting the survey did not reflect their charity's interests.In summary, sport and arts projects benefit mental and physical health; however, sport may not be prioritised by service providers, service users, and the public themselves as an intervention for well being in children. This may explain why few charities anticipated that they would contribute to a health legacy of the 2012 London Olympics.The authors declare that they have no competing interests.KSB was the grant holder and PI. KSB, LAA and AP performed the literature review. LAA undertook the web-based survey and data analysis. All authors read and approved the final manuscript.


Peter Byass and colleagues compared two methods of assessing data from verbal autopsies, review by physicians or probabilistic modeling, and show that probabilistic modeling is the most efficient means of analyzing these data Cause of death data are an essential source for public health planning, but their availability and quality are lacking in many parts of the world. Interviewing family and friends after a death has occurred  provides a source of data where deaths otherwise go unregistered; but sound methods for interpreting and analysing the ensuing data are essential. Two main approaches are commonly used: either physicians review individual interview material to arrive at probable cause of death, or probabilistic models process the data into likely cause(s). Here we compare and contrast these approaches as applied to a series of 6,153 deaths which occurred in a rural South African population from 1992 to 2005. We do not attempt to validate either approach in absolute terms.The InterVA probabilistic model was applied to a series of 6,153 deaths which had previously been reviewed by physicians. Physicians used a total of 250 cause-of-death codes, many of which occurred very rarely, while the model used 33. Cause-specific mortality fractions, overall and for population subgroups, were derived from the model's output, and the physician causes coded into comparable categories. The ten highest-ranking causes accounted for 83% and 88% of all deaths by physician interpretation and probabilistic modelling respectively, and eight of the highest ten causes were common to both approaches. Top-ranking causes of death were classified by population subgroup and period, as done previously for the physician-interpreted material. Uncertainty around the cause(s) of individual deaths was recognised as an important concept that should be reflected in overall analyses. One notably discrepant group involved pulmonary tuberculosis as a cause of death in adults aged over 65, and these cases are discussed in more detail, but the group only accounted for 3.5% of overall deaths.There were no differences between physician interpretation and probabilistic modelling that might have led to substantially different public health policy conclusions at the population level. Physician interpretation was more nuanced than the model, for example in identifying cancers at particular sites, but did not capture the uncertainty associated with individual cases. Probabilistic modelling was substantially cheaper and faster, and completely internally consistent. Both approaches characterised the rise of HIV-related mortality in this population during the period observed, and reached similar findings on other major causes of mortality. For many purposes probabilistic modelling appears to be the best available means of moving from data on deaths to public health actions.Please see later in the article for the Editors' Summary Whenever someone dies in a developed country, the cause of death is determined by a doctor and entered into a “vital registration system,” a record of all the births and deaths in that country. Public-health officials and medical professionals use this detailed and complete information about causes of death to develop public-health programs and to monitor how these programs affect the nation's health. Unfortunately, in many developing countries dying people are not attended by doctors and vital registration systems are incomplete. In most African countries, for example, less than one-quarter of deaths are recorded in vital registration systems. One increasingly important way to improve knowledge about the patterns of death in developing countries is “verbal autopsy” (VA). Using a standard form, trained personnel ask relatives and caregivers about the symptoms that the deceased had before his/her death and about the circumstances surrounding the death. Physicians then review these forms and assign a specific cause of death from a shortened version of the International Classification of Diseases, a list of codes for hundreds of diseases.Physician review of VA forms is time-consuming and expensive. Consequently, computer-based, “probabilistic” models have been developed that process the VA data and provide a likely cause of death. These models are faster and cheaper than physician review of VAs and, because they do not rely on the views of local doctors about the likely causes of death, they are more internally consistent. But are physician review and probabilistic models equally sound ways of interpreting VA data? In this study, the researchers compare and contrast the interpretation of VA data by physician review and by a probabilistic model called the InterVA model by applying these two approaches to the deaths that occurred in Agincourt, a rural region of northeast South Africa, between 1992 and 2005. The Agincourt health and sociodemographic surveillance system is a member of the INDEPTH Network, a global network that is evaluating the health and demographic characteristics  of populations in low- and middle-income countries over several years.The researchers applied the InterVA probabilistic model to 6,153 deaths that had been previously reviewed by physicians. They grouped the 250 cause-of-death codes used by the physicians into categories comparable with the 33 cause-of-death codes used by the InterVA model and derived cause-specific mortality fractions (the proportions of the population dying from specific causes) for the whole population and for subgroups  from the output of both approaches. The ten highest-ranking causes of death accounted for 83% and 88% of all deaths by physician interpretation and by probabilistic modelling, respectively. Eight of the most frequent causes of death—HIV, tuberculosis, chronic heart conditions, diarrhea, pneumonia/sepsis, transport-related accidents, homicides, and indeterminate—were common to both interpretation methods. Both methods coded about a third of all deaths as indeterminate, often because of incomplete VA data. Generally, there was close agreement between the methods for the five principal causes of death for each age group and for each period of time, although one notable discrepancy was pulmonary (lung) tuberculosis, which accounted for 6.4% and 21.3% of deaths in this age group, respectively, according to the physicians and to the model. However, these deaths accounted for only 3.5% of all the deaths.These findings reveal no differences between the cause-specific mortality fractions determined from VA data by physician interpretation and by probabilistic modelling that might have led to substantially different public-health policy programmes being initiated in this population. Importantly, both approaches clearly chart the rise of HIV-related mortality in this South African population between 1992 and 2005 and reach similar findings on other major causes of mortality. The researchers note that, although preparing the amount of VA data considered here for entry into the probabilistic model took several days, the model itself runs very quickly and always gives consistent answers. Given these findings, the researchers conclude that in many settings probabilistic modeling represents the best means of moving from VA data to public-health actions.http://dx.doi.org/10.1371/journal.pmed.1000325.Please access these Web sites via the online version of this summary at PLoS MedicinePerspective by Colin Mathers and Ties BoermaThe importance of accurate data on death is further discussed in a perspective previously published in vital registration of deaths and on the International Classification of Diseases; the WHO Health Metrics Network is a global collaboration focused on improving sources of vital statistics; and the WHO Global Health Observatory brings together core health statistics for WHO member statesThe World Health Organization (WHO) provides information on the INDEPTH Network is a global collaboration that is collecting health statistics from developing countries; it provides more information about the Agincourt health and socio-demographic surveillance system and access to standard VA formsThe Agincourt health and sociodemographic surveillance system is available on the University of Witwatersrand Web siteInformation on the InterVA Web site provides resources for interpreting verbal autopsy data and the Umeå Centre for Global Health Reseach, where the InterVA model was developed, is found at http://www.globalhealthresearch.netThe PLoS Medicine Essay by Peter Byass, lead author of this study, discusses The Unequal World of Health DataA recent  Throughout the history of public health, the concept of recording causes of individual deaths in a population and presenting them in aggregate form has been a central component of understanding health and disease at the community level. This continues to be the case, even though the extent and quality of cause of death data varies widely around the world For a large proportion of the world's communities in which individual deaths are not routinely recorded and classified by cause as part of routine civil and health service procedures, verbal autopsy (VA) has become an important technique However, the outputs from probabilistic models have some technical differences from those typically generated by physicians, since the likelihood of a particular cause of death is also estimated quantitatively as part of the modelling. Several likely causes can be reported for a single case, and a case may remain partially or wholly indeterminate, particularly where the VA interview material is scanty. These characteristics might seem problematic from a clinical perspective that instinctively seeks a conclusive single main cause of death for each case . However, since VA is normally applied as a step towards community-based analyses of cause-specific mortality and public health implications, rather than as an endpoint whose primary concern is the individual case, the outcomes are essentially epidemiologically rather than clinically oriented. The proportions of deaths within a population attributable to a particular cause  are particularly important. Thus some uncertainty at the individual level, and possibly multiple causes per case, are not in themselves problematic, but need analytical approaches that make good sense of the data. The public health imperative to understand causes of death in terms of age and sex is also important, in order to understand burdens of premature mortality, to target potential interventions, and to inform health systems development.http://www.indepth-network.org), is taken to illustrate the approaches used. Existing physician-interpreted findings from the same dataset are compared with modelled results in the sense of how they are derived and analysed, leading to some comparisons between the two approaches. However, the intention here is not to validate either approach; rather the emphasis is on interpretation and analysis processes which can lead effectively from data on deaths to public health imperatives.In this paper we aimed to assess appropriate methods for analysing and interpreting VA interview data at the population level, using both probabilistically modelled and physician-interpreted results. An example dataset from the Agincourt health and sociodemographic surveillance site (HDSS) in South Africa, a member of the INDEPTH Network  and processed into cause of death data. The InterVA model is based on Bayesian calculations of probabilities that a particular death was due to particular causes, given a set of symptoms and circumstances associated with the death. This is achieved using a probability matrix which generically estimates probabilities of particular symptoms and circumstances of death, given particular causes. The model was developed using an expert panel and was deliberately designed to be generic and not context-dependent, and to produce relatively broad cause-of-death categories The same VA interview data were compiled into an input file for the InterVA v.3 probabilistic VA interpretation model  may take some days for a data manager, but processing the file into causes of death using the model then only takes a matter of minutes. This contrasts with thousands of hours of physician time, and a cost in the region of US$20,000, for reviewing a dataset of this size. The model is also totally internally consistent, meaning that rerunning data produces exactly the same output, and there is also therefore complete consistency at the individual case level over time, when considering a series of deaths that actually occurred over many years. With physician interpretation, it is unlikely that the same physicians can be available to undertake this work over an extended period, and in any case it is probable that their thinking and understanding would change over time. The model provides up to three likely causes of death for each case, or concludes that the cause is indeterminate. Each cause assigned is associated with a likelihood, and the sum of likelihoods of assigned causes has a maximum value of 1.00. If the sum of likelihoods of assigned causes is less than 1.00, then the difference reflects a lack of certainty about the overall case. It therefore seems logical to regard this uncertain proportion of each case as an indeterminate component.For analysis, a dataset was constructed from the model's output (using Microsoft FoxPro) in which each case had one or more records, each record having one cause (including the possible cause “indeterminate”) and a weight corresponding to the likelihood of that cause for the particular case. Thus over the whole dataset, the sum of all the weights was equal to the number of cases, 6,153. This dataset included a total of 11,834 records, an average of 1.92 per case. This data structure also facilitates the import of other background factors of interest , which can then be analysed against particular causes of death in a weighted multivariate model. Physician-interpreted material where consensus on a single main cause is required can be analysed in very similar ways, with the conceptual weighting for each case being 1.The analyses presented here were carried out using Stata 10.Surveillance-based studies in the Agincourt subdistrict were reviewed and approved by the Committee for Research on Human Subjects  of the University of the Witwatersrand, Johannesburg, South Africa (protocol M960720). Informed consent was obtained at the individual and household levels at every follow-up visit, whereas community consent from civic and traditional leadership was secured at the start of surveillance and reaffirmed from time to time.The same 6,153 deaths as presented previously using physician-interpreted causes The overall proportion of indeterminate cases was 31.0%, compared with 34.8% in the physician review process. This indeterminate category included 359 deaths for which verbal autopsies were not successfully completed. In the InterVA model, a further 375 cases were rated as completely indeterminate, and the summed weights of the uncertain proportion of the remaining cases totalled 1,170.9, an average uncertainty per case of 24.3%. In the physician coding, 1,609 individual cases were considered to be indeterminate, either because of insufficient information or failure to reach a consensus between assessing physicians. The physicians considered a further 173 cases as indeterminate for particular reasons, for example sudden deaths of unknown cause. It was also interesting to note that the physician coding process led to using a total of 250 different ICD-10 codes, but the ten most frequently used ICD-10 codes accounted for 70.7% of the deaths.One instance in which there was a clear difference in the estimates between the physician-coded and modelled findings was in tuberculosis as a cause of death among the elderly (over 65 years). According to the physicians, 96/1,492 (6.4%) of deaths in this age group were due to tuberculosis, compared with 318.4/1,492 (21.3%) according to the model. Of the 96 cases reported as tuberculosis by the physicians, 78 (81.3%) were also concluded to be tuberculosis by the model. However, among the 241 cases rated as tuberculosis by the model but not by the physicians, 103 (42.7%) were rated as indeterminate by the physicians. To elucidate this difference, Having considered the causes of more than 6,000 deaths over a 14-year period, the ten highest-ranking causes accounted for 83% and 88% of all deaths by physician interpretation and probabilistic modelling respectively, and eight of the highest ten causes were common to both approaches. Probabilistic modelling was cheaper and more internally consistent than physician interpretation. Uncertainty around the cause(s) of individual deaths was recognised as an important concept that should be reflected in any overall analysis of cause-specific mortality.The advantages and disadvantages of physician-interpreted and probabilistically modelled cause of death data as evidenced by these analyses were largely as anticipated. Physician-interpreted findings included a number of quite specific, but rare, causes which were not designed to be addressed by the current model. While it is possible to build similar models with more detailed inputs and outputs, as has been done for deaths among women of reproductive age The methods described here for analysing the probabilistically modelled cause of death data are relatively straightforward, taking into account that particular causes of death have been modelled with a specific likelihood and the quantifiable margin of uncertainty associated with many individual cases. These methods allow the margins of uncertainty associated with individual cause of death assignments to be carried through into the aggregated analysis process.When physicians are used to assess VA material, and particularly if, as was the case for these data, physician consensus on individual cases is taken to be an important part of the process Given the very different approaches to cause-of-death interpretation and analysis as presented here and in the earlier paper , it is perhaps remarkable that many of the salient features of There are also some potentially important differences emerging from the two approaches, even though they are not huge in the context of the entire dataset. In considering any such differences, it has to be recognised that there is no gold standard available here. Kahn et al. have previously undertaken a validation exercise between physician assessments and a limited number of well-justified hospital-based diagnoses Notable differences that do emerge include lower estimates of malignant disease in the InterVA findings and lower estimates of tuberculosis among the elderly in the physician data. The InterVA model also gave higher estimates of HIV-related mortality in the first period (1992–94), which is particularly interesting to note. This early difference may reflect a degree of false-positive HIV-related findings by the model during a period of lower HIV-prevalence, and this needs to be further investigated in terms of characterising the overall HIV prevalence for the model as “high”. On the other hand, it might reflect a difficulty among the physicians in achieving consensus on HIV as a cause of death in those relatively early days of the epidemic, and this is also something to look into further. It seems likely that during the onset of the epidemic, individual physicians' perceptions of new disease patterns might have developed quite rapidly, but not necessarily in the same ways and at the same rates, depending on their personal experiences. This process, at least for a while, might have increased the difficulties in achieving consensus on HIV-related causes. The reported rate of ill-defined or unknown causes was highest in the physician-coded material for the period 1992–94 (approximately one-third), falling to approximately one-fifth by 2002–04 The examples of factors leading to tuberculosis as a cause of death among the elderly, as detailed in The importance of conceptual categorisations of cause of death can also be seen in these comparisons. At first sight, it appears that the approaches  gave dif“If I were the local Director of Public Health…”. From these data, and irrespective of the methods used for analysis and interpretation, it is clear that the Agincourt population has undergone rapid changes, which imply new intervention target groups, expanded demands on health professionals' skills, changing demands on health services and increasing resource requirements. The pictures of the major public health themes within the Agincourt population that emerge from both of the interpretative approaches considered are encouragingly similar, both in terms of overall cause-specific mortality patterns and in the ways that they have tracked changes over time, and the adoption of one or other method of interpretation would not lead to fundamentally different public health actions. The clear development of the HIV epidemic revealed in this example, and seeing which population subgroups are vulnerable to particular diseases, both highlight some of the advantages of using VA as a public health tool. At least where VA is used within routine health services, probabilistic modelling with its consistent approach over time and place, the elimination of inter- and intra-assessor variation, faster results, and much lower cost, should be the interpretative method of choice.The main aim of this paper is not to provide a validation of any particular VA method, but to consider alternative approaches for handling interview data on individual deaths to give meaningful pictures of population health. These data are the basic resource for public health planning: the questions in our minds throughout these considerations have started from


The objective of the present study was to assess heritability of clinical and radiographic features of hand osteoarthritis (OA) in affected patients and their siblings.A convenience sample of patients with clinical and radiographic hand OA and their siblings were evaluated by examination and radiography. Radiographs were scored for hand OA features by radiographic atlas. The heritability of hand OA phenotypes was assessed for clinical and radiographic measures based on anatomic locations and radiographic characteristics. Phenotypic data were transformed to reduce non-normality, if necessary. A variance components approach was used to calculate heritability.h2 = 0.63, P = 0.00004), the first carpometacarpal joint , the distal interphalangeal joints , and the proximal interphalangeal joints  with osteophytes. The number and severity of joints with osteophyte involvement was heritable overall  and for all interphalangeal joints . The severity of carpometacarpal joint involvement was also heritable . Similar results were obtained when the analysis was limited to the Caucasian sample.One hundred and thirty-six probands with hand OA and their sibling(s) were enrolled. By anatomic location, the highest heritability was seen with involvement of the first interphalangeal joint (In a population with clinical and radiographic hand OA and their siblings, the presence of osteophytes was the most sensitive biomarker for hand OA heritability. Significant heritability was detected for anatomic phenotypes by joint location, severity of joint involvement with osteophytes as well as for overall number and degree of hand OA involvement. These findings are in agreement with the strong genetic predisposition for hand OA reported by others. The results support phenotyping based on severity of osteophytes and a joint-specific approach. More specific phenotypes may hold greater promise in the study of genetics in hand OA. Osteoarthritis (OA), a polymorphic condition, is a disease of articular cartilage and bone accompanied by subchondral bone thickening, bony outgrowths, and mild chronic synovitis. Hand OA is one of the most common types of OA in developed countries, and is more prevalent in perimenopausal and postmenopausal women. The incidence and prevalence of hand OA has been shown to increase with age; after age 50, women have higher rates than men ,2. In coOne of the difficulties in addressing hand OA has been the absence of an agreed-upon optimal definition to characterize patients for study. Previous heritability studies have been in different types of patient groups , with most studies using variable definitions of radiographic OA regardless of whether the manifestations of hand OA were clinically present. Most of these studies evaluated the heritability of generalized OA in subjects with involvement of multiple sites, including the hand, knee, hip or spine, but were not specific to hand OA itself. To better understand the specific phenotypes of hand OA, we have undertaken a heritability assessment of our population to see which types of clinical and radiographic features have the greatest heritability. Differential heritability estimates for various traits may contribute to better understanding of the etiology of potential risk factors for hand OA. As part of an ongoing genetic study, subjects with hand OA were recruited for a family-based study and were characterized for clinical and radiographic signs of hand OA.The study subjects were recruited as part of the Genetics of Hand Osteoarthritis Study, aimed at assessing genetic determinants of symptomatic and radiographic hand OA in sibling pairs. The study is based in Los Angeles, CA, USA. Oral and written consent were required from all participants. The protocol was approved by the Institutional Review Board of Cedars-Sinai Medical Center, Los Angeles, CA, USA.Consecutive, unrelated subjects (probands) with symptomatic , idiopathic (primary) OA of the hand - in the distal interphalangeal joint (DIP) and/or proximal interphalangeal joint (PIP) and/or first carpometacarpal joint (CMC) - were invited to participate as part of a family study. Subjects were recruited by newspaper and electronic advertisement , mailings in the greater Los Angeles area, and by referral from local rheumatologists and hand surgeons. Study enrollment began in January 2006 and is ongoing.For inclusion in this study, these subjects must be ≥ 45 years of age, meet American College of Rheumatology clinical classification criteria for OA, and have radiographic evidence of OA in the form of osteophytes scored by a validated atlas in either the trapeziometacarpal (first CMC) joint or at least two DIP or PIP joints ,10. ProbParticipating subjects completed a questionnaire reporting demographic data, medical history, medication history, hormone exposure, family history and other sites of OA. All probands and onsite siblings underwent physical examination for signs of hand OA by a single investigator (MLI) at a hospital-based dedicated research facility, along with symptom assessments, hand photography, radiography and blood draw. For offsite siblings, hand X-ray scans were obtained using a standard protocol and blood was drawn in their area of residence. In addition, all probands completed the Australian/Canadian OA Hand Index using a five-point Likert-scale format that contains 15 questions divided into three areas: pain (five questions), stiffness (one question) and physical function (nine questions).A posterior radiograph of both hands was obtained and blood was collected for genetic analysis. Blinded hand radiographs were scored by a single reader (RDA), without knowledge of the study subject's other data. Radiographs were scored by an atlas for osteophytes (0 to 3), sclerosis (0 to 3), joint space narrowing (0 to 3), subchondral cysts (presence/absence) and erosions (presence/absence) . RandomiThe frequency and heritability of radiographic hand OA phenotypes were assessed. The phenotypes included overall hand OA involvement as measured by the Total Count and the Total Score, and radiographically assessed phenotypes based on anatomic locations of joint groups (DIP ± PIP ± CMC) and radiographic characteristics, such as joint space narrowing, osteophytes, or subchondral erosions. The scores for each type of radiographic feature were summed for the 10 joints in each hand on a quantitative scale, and a total score was obtained ranging from 0 to 60.2p) was partitioned into the variance due to the additive effects of genes (σ2G) and the variance due to environmental effects (σ2E). The genetic effect was assumed to be independent and normally distributed with zero mean and variance of σ2G. The heritability (h2) of each trait, which quantifies the extent to which genetic variation contributed to the expression of the specific phenotypes, independent of disease prevalence, was calculated by the genetic variance divided by the total phenotypic variance. Age, gender and body mass index were included as covariates in the analysis to adjust for potential confounding effect. The heritability was calculated using SOLAR software  [Subjects and their siblings were assessed for the agreement of specific phenotypic traits within their family. Phenotype traits were transformed (log or square-root) to reduce non-normality if necessary. The variation in each trait was assumed to be a linear combination of covariate effects, genetic effect and residual variability. A variance components approach was used in which the total phenotypic variance  . We perfOne hundred and thirty-six families consisting of probands and at least one sibling were enrolled. Of these families, 150 siblings were enrolled and 77 of the siblings were enrolled onsite with a complete examination of the hands. As expected, the majority of the probands were women. Among the siblings, 32% (48/150) were men. Most participants were over 60 years of age, were Caucasian, had disease for over 10 years, and were only mildly overweight  and the CMC joint , but with significant heritability estimates for the DIP joints  and the PIP joints  (Table P = 0.004); for the Total Count, which also included CMC joints, the heritability estimate was 0.38 (P = 0.008).After adjusting for age, gender and body mass index, our results revealed that the greatest statistical significance for heritability was for radiographic osteophytes at anatomic locations in the interphalangeal joints of probands and siblings, with the highest heritability seen for the involvement of the IP joint , the CMC score (h2 = 0.53) and the DIP/IP/PIP count (h2 = 0.42), which were based on the presence of osteophytes. We also observed that disease severity as assessed by the presence of osteophytes, a classic hand OA feature, was heritable, with greater involvement in the number of joints and severity per joint seen in sibling pairs. This finding was observed despite the fact that siblings were invited to participate regardless of their hand OA status. The heritability of these individual phenotypes supports the argument that phenotyping based on severity of osteophytes and location of disease is an important consideration for a genetic study.The main goal of the present study was an attempt to demonstrate which clinical and/or radiographic phenotypes of hand OA might have the highest heritability in a condition known to have a genetic risk. The highest heritability estimates were observed for the first IP count and score  that could impact on its interpretation and generalizability. Our collection is a convenience sample and the current analysis focused on 136 completed families. There are other families for whom the sibling enrollment has not yet been completed, and the study enrollment continues. In addition, the enrollment of any available sibling may lead to some selection bias, as those siblings affected by hand OA may be more likely to participate. Whenever possible, every attempt was made to enroll as many siblings per family as possible - although given the average age of the subjects (65.5 years), in some instances certain siblings were either too ill or deceased and could not participate. At the time of this study, the completed families represented 74.7% of probands with available siblings.Ultimately, this cohort will be studied to assess for genetic associations, for which a bias towards affected sibling participation may potentially be an advantage, as an enriched population for genetic study. For some phenotypes with an observed trend toward significance, a larger sample size will need to be studied. The family structure is also simplified, with analysis of siblings only, which may limit the interpretability of variance component analysis and the possible contribution of a common environment is therefore difficult to evaluate. In this analytic situation, the heritability estimate is the upper bound and includes the possible common environment. In most cases, due to the age of the study patients and their siblings, very few parents are living, and the offspring may be too young to enroll as they may not as yet have expression of hand OA. Nevertheless, the subjects who have been enrolled have been carefully phenotyped radiographically.For the clinical characteristics contributed by a physical examination, the sample size is limited to the 77 families in whom enrollment was completed onsite. This does limit the sample size for these clinical phenotypes. As many study subjects were referred from rheumatology or hand surgery practices, our patients may also possess a more severe form of hand OA when compared with the general, community-based population. The study population was predominantly Caucasian women, of whom 40% were of Ashkenazi Jewish descent, which may potentially lead to bias. For genetic analyses, however, more severe forms of disease expression and more genetically homogeneous populations may identify groups with greater genetic predisposition.There are inherent limitations to heritability studies. While a higher heritability suggests that the phenotype is a good predictor of genotype, it does not automatically mean that knowing the genotype determines the phenotype; other factors may come into play. Additional limitations to heritability analysis include the following: heritability is a measure of correlation and does not identify genes; there is no direct correlation between higher heritability and genes of larger effect; heritability estimates can vary from one population to another; heritability does not preclude environmental influences on a trait; and in heritability analyses limited to siblings, the heritability estimate should be considered an upper bound, confounded, in part, by the common sibling environment. Nevertheless, assessment of heritability is considered an appropriate first step before one proceeds in efforts to identify genes.In an attempt to analyze heritability, the subdivision of the population into the phenotypes of joint location and clinical and radiographic features may lead to smaller sample sizes for some groups, which may limit the utility of a given analysis. With the dearth of information available regarding carefully characterized phenotypes in hand OA in the literature, however, even an analysis of the smaller sample will help guide the phenotypes upon which to focus future genetic analysis. Genetic studies of hand OA to date have used clinical phenotypes, radiographic phenotypes or anatomic location for genetic studies. It is possible that the dissimilarity of analyzed OA features has lead to a difficulty in reproducing genotype associations in different studies ,16. The In our study of 136 probands with clinical and radiographic hand OA and of 150 siblings, the presence of osteophytes was the most heritable feature compared with other clinical and radiographic phenotypes. Significant heritability was detected for radiographic involvement with osteophytes overall and by joint location and severity, with the highest heritability estimates for the involvement of the first IP and CMC. These findings are in agreement with the strong genetic predisposition for hand OA reported by others. It is possible to hypothesize that there may be a heritable component to hand OA that contributes to the concept of osteophyte load as well as the site of affected joints. Our analysis also supports phenotyping on the basis of osteophyte severity and a joint-specific approach, as more specific phenotypes may hold greater promise in the study of the genetic basis of hand OA.CMC: carpometacarpal joint; DIP: distal interphalangeal joint; IP: interphalangeal joint; OA: osteoarthritis; PIP: proximal interphalangeal joint.The authors declare that they have no competing interests.MLI contributed to conception and design, acquisition of data, analysis and interpretation of data, drafting of the article and final approval of the submitted manuscript. RDA contributed to the conception and design of the study, the acquisition and interpretation of data, revision for important intellectual content and final approval of the manuscript. MJC contributed to the provision of patients, acquisition of data, revision for important intellectual content and final approval of the manuscript. JC contributed to analysis and interpretation of data, revision for important intellectual content and final approval of the manuscript. XG contributed to the design of the study, analysis and interpretation of data, revision for important intellectual content and final approval of the manuscript. JIR contributed to conception and design of the study, revision for important intellectual content and final approval of the manuscript. MHW contributed to conception and design of study, revision for important intellectual content and final approval of the manuscript. MLI and MHW take responsibility for the integrity of the research and manuscript, from inception to finished article.


The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry and the Ethical Principles of Psychologists and Code of Conduct, respectively. In this way, all physicians and psychologists will clearly understand that they have an absolute moral obligation to "First, do no harm" to the human beings they professionally encounter.After revelations of participation by psychiatrists and psychologists in interrogation of prisoners at Guantánamo Bay and Central Intelligence Agency secret detention centers, the American Psychiatric Association and the American Psychological Association adopted Position Statements absolutely prohibiting their members from participating in torture under any and all circumstances, and, to a limited degree, forbidding involvement in interrogations. Some interrogations utilize very aggressive techniques determined to be torture by many nations and organizations throughout the world. This paper explains why psychiatrists and psychologists involved in coercive interrogations violate the Geneva Conventions and the laws of the United States. Whether done with ignorance of professional ethical obligations or not, these psychiatrists and psychologists have crossed an ethical barrier that may best be averted from re-occurring by teaching medical students and residents in all medical specialties about the ethics principles stemming from the 1946–1947 Nuremberg trials and the Geneva Conventions, together with the Ethics Codes of the World Medical Association and the American Medical Association; and, with regard to psychiatric residents and psychological trainees, by the teaching about  The COR, like the AΨA Assembly, is a lively debating society in which the views of many representatives are expressed with passion and conviction; it is made up of strong-minded people selected by their APA branches to represent their views . The CORThe AΨA Assembly, in comparison with the COR, has, as mentioned, very little power. It serves as the representative legislative component of the AΨA. Consisting of some 250 members, of whom approximately 160 are voting members , the Assembly represents the members of the Association and acts for them in the affairs of the Association. Additionally, it provides a means for representing the needs of District Branches and for reciprocal communication between the District Branches and other governing bodies of the Association . It is cf " . Many otcoercive interrogation. It was pointed out at that time that military psychiatrists from the Society of Uniformed Services Psychiatrists are especially supportive of this language because they felt that the Board's language was too restrictive and could hamper their efforts to help the government and detainees. Some Assembly members also believe that there is no evidence indicating that any physician has been involved in the degrading aspects of interrogation."Contrary to what is generally believed, adoption of the AΨA Position Statement was delayed by about six months, and did not receive unanimous approval by either the AΨA Assembly or Board of Trustees. Before describing how the Board of Trustees came to the decision to retain the Position Statement as originally drafted, it is important to further examine why the Assembly voted to so drastically amend the Statement. The then Speaker of the Assembly offered the following explanation (Joseph Rubin Email to [Assembly] Area Council members 02/16/2006): "During the November 2005 Assembly meeting, the Assembly amended the position statement, using terminology opposing psychiatric participation in k  by amendment or tabling" it when it is presented to the Assembly for their approval at their meeting on November 11–14, 2005 (A.L.H. Email to Steven Sharfstein 11/02/2005). Dr. Sharfstein thanked us for alerting him . As mentioned above, the Assembly added the word "coercive" , therebyA few days prior to the AΨA Board meeting, the Board received a letter from Leonard Rubenstein, J.D., the Executive Director of Physicians for Human Rights (PHR), in essence recommending that the AΨA Position Statement "be limited to interrogations outside the U.S. justice system (Leonard Rubenstein Letter to Steven Sharfstein and members of the APA Board of Trustees 12/07/2005). Such a change would still result in the Position Statement exempting participation by psychiatrists in interrogations by police officials and other authorities within the United States, and, as such, could pose a serious risk of misuse and abuse of psychiatry. We wrote to Dr. Sharfstein and several members of the Board of Trustees, including Dr. Paul Appelbaum, on December 8, strongly urging them not to accept the suggestion of PHR . We received a positive response from Dr. Appelbaum indicating that he would do what he could to see that our recommendation was accepted by the Board (Paul Appelbaum Email to A.L.H. 12/08/2005). On December 9, Mr. Rubenstein, wrote to Dr. Freedman indicating that PHR had intended only to suggest a compromise in the event that the differences in the positions of the Board and the Assembly could not be resolved, and that PHR was withdrawing its suggestion and was entirely supportive of the Board's original Statement unchanged (Leonard Rubenstein Email to Alfred Freedman 12/09/2005).At the Board of Trustees meeting, although some members opposed the original Position Statement, the Board voted unanimously "to reaffirm the position statement approved at the October 2005 Board meeting, with the understanding that the Board will initiate a dialogue with Assembly leaders and with as many Assembly members as possible before the May 2006 Assembly meeting to approve a joint statement." The AΨA President and Speaker were to appoint Board and Assembly members representing both sides of this issue to an ad hoc work group with a charge to propose recommendations in time for the May 2006 Assembly and Board meetings (Joseph Rubin Email to [Assembly] Area Council members 02/16/2006). The purpose of this committee was to see if some revision of the Statement could be developed that would accommodate both the Board's and Assembly's versions of the Position Statement. The position of the military and forensic psychiatrists in the Assembly was clearly presented; nevertheless, although the committee members were not unanimous, the committee voted to recommend to the Assembly that the Board's original Position Statement on Psychiatric Participation in Interrogation of Detainees become official AΨA policy. The position (fully consistent with the "forensicist" views discussed above) of the forensic psychiatry and military Assembly representatives, strongly supportive of the amendment to limit the prohibition of psychiatrist participation to "coercive" interrogations, was well summarized by Joseph Rubin, M.D., as follows (Joseph Rubin (Speaker of Assembly) Email to James Nininger (Speaker-Elect) and Thomas Grieger (Representative of the Society of Uniformed Services Psychiatrists) 02/17/2006):The Assembly representatives from the work group agreed that the revised document narrows the differences between the previously stated positions and broadens the potential role of psychiatrist participation. However, the Assembly representatives believe that there may be benefit to psychiatrists advising on non-coercive interview techniques related to particular detainees. For forensic psychiatrists, the primary value of their work is to advance the interests of justice. Trying to introduce the principles of medical ethics for treatment into a theory of ethics for forensic psychiatry heightens the problem of dual agency. When serving the interests of justice, forensic psychiatrists must adhere to the general moral rules of disclosure and respect for patients. If the role of the psychiatrist is made clear, and there are prohibitions against cruel, inhuman, or humiliating conditions, psychiatrists consulting to interviewers of detainees can adhere to general ethical principles. Enhanced gathering of information may assist in the pursuit of justice, identification of other dangerous individuals, or the curtailment of future acts against society.Forensic psychiatrists routinely provide direct examination of individuals charged with crimes for purposes other than providing treatment . Psychiatrists also assist defense counsel in working with distrusting clients, prosecuting attorneys examining witnesses during trial and law enforcement or correctional authorities gathering information from suspects, crime witnesses, or prisoners with behavior problems. Suggestions for interviewers in these settings  are similar in many ways to the supervision and training we provide to psychiatry residents and medical students as they develop their interviewing skills. These suggestions might include the pacing and phrasing of questions, observation of non-verbal cues provided by the person being questioned, selection of an alternative interviewer, and changing the length or frequency of interview sessions.l. This, apparently inadvertently overlooked by Dr. Appelbaum, negates his assertion, noted in "The Forensicist" section above, that "The forensic psychiatrist in truth does not act as a physician."Very apprehensive that, notwithstanding the ad hoc committee's recommendation, the AΨA Assembly might persist in their efforts to amend the Position Statement (and thus create a dispute between the Assembly and Board of Trustees that would be very embarrassing for the AΨA), we urged Dr. Appelbaum to make a presentation to the Assembly when it took up the matter of the Position Statement again at its meeting on May 21, 2006 (A.L.H. Email to Paul Appelbaum 05/17/2006). Dr. Appelbaum, as noted above, had already agreed with our strong objections to the amended Position Statement, notwithstanding the position of his fellow "forensicists" in the Assembly (Paul Appelbaum Email to A.L.H. 12/08/2005). Accordingly, as a member of the Board of Trustees and designated to represent the Board, he addressed the Assembly and explained the reasons for the Board's Position Statement, emphasizing the facts that "interrogations are inherently deceptive/coercive, and hence inappropriate for physicians to be involved" and "involvement undercuts the physician's role as treater, because detainees are unlikely to trust physicians when they know that they or their colleagues participate in interrogations"In the end, the Assembly, by a majority vote, approved the Board of Trustees' original Position Statement on Psychiatric Participation in Interrogation of Detainees, which became official AΨA policy as of May 21, 2006. .AΨA Position Statement on Psychiatric Participation in Interrogation of Detainees does not justify the AΨA's presenting itself to the world as an organization adhering, in the matter of interrogation of detainees using techniques condemned by all civilized nations, more faithfully to principles of ethics than the APA. A relatively small number of psychologists and psychiatrists, no doubt, like forensicists, are convinced that they operate "outside the bounds of the doctor-patient relationship and [are] thus not required to abide by accepted ethical guidelines" f," Hitchens adds, "waterboarding does not constitute torture, then there is no such thing as torture."g) Although, as reported in The New York Times, waterboarding involves strapping a suspect in a board with feet elevated, covering his face with a cloth and pouring water on it to produce a feeling of suffocation (mock drowning) , waterboh) These techniques were based in large part on techniques of torture and cruelty used by the U.S. military in its Survival, Evasion, Resistance, and Escape (SERE) program. The SERE program, itself "based on Chinese techniques used in the 1950s that produced false confessions from American prisoners" , was inti) Later in 2002, the "Behavioral Science Consultation Team" (BSCT) was created at Guantánamo in order to develop new strategies for interrogation and assess intelligence production ,74. The j) This opinion defining torture was ostensibly withdrawn two years later; however, a Justice Department spokesman has stated, according to an Associated Press report , that "tk) This brings to mind the comment by George Annas : "BlocheThe Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.l) Dr. Appelbaum's persuasive comments are noted in a memorandum to the Speaker just prior to the stormy session in the Assembly about the Position Statement: "Why should psychiatrists not advise interrogators on strategies to take with particular detainees? Interrogations, even when conducted legally, are inherently coercive and deceptive; coercive because a detainee who wanted to talk would not have to be interrogated; deceptive because interrogators are trained to mislead suspects and are supported by the law in doing so. The purpose of an interrogation is to pressure or trick the detainee into revealing information that the detainee does not want to disclose. These may be legitimate functions for law enforcement. But psychiatric ethics–even as applied in forensic evaluations, which may be the closest analogue–require us to obtain consent before questioning a person, and preclude our lying to them to obtain information. When forensic psychiatrists conduct an interview, the purpose is to assess the person's mental state. Here, however, the purpose of involvement is to extract information, and the psychiatrist's job is to guide interrogators in doing so. Having psychiatrists so closely allied with the policing function of the state threatens to compromise our healing mission. That most people consider this to be an inappropriate role for any physician seems apparent from the public reaction to recent allegations of physician involvement in interrogations. Our profession would be best served if we too recognized the inappropriateness of our playing this role." It is clear to the authors of this article that Dr. Appelbaum by his statement, particularly his reference to "the inappropriate role for any physician," has failed to see that, by extrapolation, his words can apply to the "forensicist." It is hoped that forensic psychiatrists will now understand that a special ethics code for forensic psychiatrists is unwarranted, and that they, along with all other psychiatrists, are honor bound to abide by The authors declare that they have no competing interests.ALH conceived this paper's topic, and all authors participated in the coordination of reviewed materials and helped draft the manuscript. All authors read and approved the final manuscript.Abraham L. Halpern M.D. is Emeritus Professor of Psychiatry at New York Medical College. He is a past president of both the American Academy of Psychiatry and the Law, and the International Academy of Law and Mental Health.John H. Halpern M.D. is Assistant Professor of Psychiatry, Harvard Medical School; Director of the Laboratory for Integrative Psychiatry, Addictions Division, and Associate Director of Substance Abuse Research, Biological Psychiatry Laboratory, McLean Hospital.Sean B. Doherty BSc. (Hons) is a fifth year medical student at Cardiff University (as part of the Swansea University GEP medicine course). He received the 2008 Royal College of Psychiatry Medical Elective Bursary, which helped fund his current two-month placement as a research assistant at the Laboratory of Integrative Psychiatry, Addictions Division, McLean Hospital, Belmont, MA.


PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the Web sites of  This paper describes the recommendations of The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative on what should be included in an accurate and complete report of an observational study. Many questions in medical research are investigated in observational studies . Much ofResearch should be reported transparently so that readers can follow what was planned, what was done, what was found, and what conclusions were drawn. The credibility of research depends on a critical assessment by others of the strengths and weaknesses in study design, conduct, and analysis. Transparent reporting is also needed to judge whether and how results can be included in systematic reviews ,5. HowevRecommendations on the reporting of research can improve reporting quality. The Consolidated Standards of Reporting Trials (CONSORT) Statement was developed in 1996 and revised 5 years later . Many meThe STROBE Statement is a checklist of items that should be addressed in articles reporting on the 3 main study designs of analytical epidemiology: cohort, case-control, and cross-sectional studies. The intention is solely to provide guidance on how to report observational research well: these recommendations are not prescriptions for designing or conducting studies. Also, while clarity of reporting is a prerequisite to evaluation, the checklist is not an instrument to evaluate the quality of observational research.PLoS Medicine (http://www.plosmedicine.org/), Annals of Internal Medicine , and Epidemiology (http://www.epidem.com/).Here we present the STROBE Statement and explain how it was developed. In a detailed companion paper, the Explanation and Elaboration article –20, we jhttp://www.strobe-statement.org/). We searched textbooks, bibliographic databases, reference lists, and personal files for relevant material, including previous recommendations, empirical studies of reporting and articles describing relevant methodological research. Because observational research makes use of many different study designs, we felt that the scope of STROBE had to be clearly defined early on. We decided to focus on the 3 study designs that are used most widely in analytical observational research: cohort, case-control, and cross-sectional studies.We established the STROBE Initiative in 2004, obtained funding for a workshop and set up a Web site  was used to facilitate discussions. The 3 draft checklists were then discussed by all participants and, where possible, items were revised to make them applicable to all three study designs. In a final plenary session, the group decided on the strategy for finalizing and disseminating the STROBE Statement.We organised a 2-day workshop in Bristol, UK, in September 2004. 23 individuals attended this meeting, including editorial staff from After the workshop we drafted a combined checklist including all three designs and made it available on our Web site. We invited participants and additional scientists and editors to comment on this draft checklist. We subsequently published 3 revisions on the Web site, and 2 summaries of comments received and changes made. During this process the coordinating group  met on eight occasions for 1 or 2 days and held several telephone conferences to revise the checklist and to prepare the present paper and the Explanation and Elaboration paper –20. The The STROBE Statement is a checklist of 22 items that we consider essential for good reporting of observational studies . These iThe STROBE Statement was developed to assist authors when writing up analytical observational studies, to support editors and reviewers when considering such articles for publication, and to help readers when critically appraising published articles. We developed the checklist through an open process, taking into account the experience gained with previous initiatives, in particular CONSORT. We reviewed the relevant empirical evidence as well as methodological work, and subjected consecutive drafts to an extensive iterative process of consultation. The checklist presented here is thus based on input from a large number of individuals with diverse backgrounds and perspectives. The comprehensive explanatory article –20, whicObservational studies serve a wide range of purposes, on a continuum from the discovery of new findings to the confirmation or refutation of previous findings –20. SomeThe STROBE Statement should not be interpreted as an attempt to prescribe the reporting of observational research in a rigid format. The checklist items should be addressed in sufficient detail and with clarity somewhere in an article, but the order and format for presenting information depends on author preferences, journal style, and the traditions of the research field. For instance, we discuss the reporting of results under a number of separate items, while recognizing that authors might address several items within a single section of text or in a table. Also, item 22, on the source of funding and the role of funders, could be addressed in an appendix or in the methods section of the article. We do not aim at standardising reporting. Authors of randomised clinical trials were asked by an editor of a specialist medical journal to “CONSORT” their manuscripts on submission . We beliWe emphasise that the STROBE Statement was not developed as a tool for assessing the quality of published observational research. Such instruments have been developed by other groups and were the subject of a recent systematic review . In the http://www.strobe-statement.org/).We did not undertake a comprehensive systematic review for each of the checklist items and sub-items, or do our own research to fill gaps in the evidence base. Further, although no one was excluded from the process, the composition of the group of contributors was influenced by existing networks and was not representative in terms of geography (it was dominated by contributors from Europe and North America) and probably was not representative in terms of research interests and disciplines. We stress that STROBE and other recommendations on the reporting of research should be seen as evolving documents that require continual assessment, refinement, and, if necessary, change. We welcome suggestions for the further dissemination of STROBE—e.g., by re-publication of the present article in specialist journals and in journals published in other languages. Groups or individuals who intend to translate the checklist to other languages should consult the coordinating group beforehand. We will revise the checklist in the future, taking into account comments, criticism, new evidence, and experience from its use. We invite readers to submit their comments via the STROBE Web site (


The electronic health record (EHR) is an important application of information and communication technologies to the healthcare sector. EHR implementation is expected to produce benefits for patients, professionals, organisations, and the population as a whole. These benefits cannot be achieved without the adoption of EHR by healthcare professionals. Nevertheless, the influence of individual and organisational factors in determining EHR adoption is still unclear. This study aims to assess the unique contribution of individual and organisational factors on EHR adoption in healthcare settings, as well as possible interrelations between these factors.A prospective study will be conducted. A stratified random sampling method will be used to select 50 healthcare organisations in the Quebec City Health Region (Canada). At the individual level, a sample of 15 to 30 health professionals will be chosen within each organisation depending on its size. A semi-structured questionnaire will be administered to two key informants in each organisation to collect organisational data. A composite adoption score of EHR adoption will be developed based on a Delphi process and will be used as the outcome variable. Twelve to eighteen months after the first contact, depending on the pace of EHR implementation, key informants and clinicians will be contacted once again to monitor the evolution of EHR adoption. A multilevel regression model will be applied to identify the organisational and individual determinants of EHR adoption in clinical settings. Alternative analytical models would be applied if necessary.The study will assess the contribution of organisational and individual factors, as well as their interactions, to the implementation of EHR in clinical settings.These results will be very relevant for decision makers and managers who are facing the challenge of implementing EHR in the healthcare system. In addition, this research constitutes a major contribution to the field of knowledge transfer and implementation science. Using such evidence in daily clinical practices could enable a safer and more efficient healthcare system [Information and communication technologies (ICTs) include a set of effective tools to collect, store, process, and exchange health-related information . In thate system ,3.Patients, professionals, organisations, and the public in general are thus expected to benefit from EHR implementation. International literature supports several benefits of EHRs for patients -11. One The implementation of EHR in healthcare systems is currently supported in many countries. In the US, the Institute of Medicine has qualified the EHR as 'an essential technology for healthcare' . The devAn increasing body of knowledge on EHR implementation shows that a majority of projects do not sustain over the experimentation phase ,25. IssuPrevious studies on factors affecting EHR adoption in healthcare settings have traditionally focused on a single aspect of this multidimensional phenomenon . As suchet al. [Other studies have explored EHR adoption determinants at different levels without considering their possible interdependence. For example, Simon et al. ,25 have In Quebec, Lapointe ,43 conduAdoption of EHR by healthcare professionals is an essential condition to ensure that its expected benefits will materialise. However, there is a gap in knowledge regarding the specific influence of individual and organisational factors in determining EHR adoption. The aim of this study is thus to assess the unique contribution of individual and organisational factors on the adoption of EHR in healthcare settings, as well as possible interrelations between these factors.Specifically, the study seeks to answer the following questions: which factors, at the individual and organisational levels (independent variables) predict EHR adoption by healthcare professionals (dependant variable)?; what are the unique contributions of individual and organisational factors in predicting EHR adoption?; and how are individual and organisational adoption factors interrelated?The phenomenon of innovation is omnipresent in the healthcare system where new technologies and interventions are constantly introduced in order to improve the health of individuals and populations. Innovation can be studied at four distinct levels: the individual healthcare professionals; the healthcare professionals groups; the healthcare organisations; and the larger healthcare system . SeveralMany theoretical models have been used to investigate the organisational characteristics influencing technology adoption. Given the particular nature of healthcare organisations, Mintzberg's configuration theory  and the The organisational theoretical framework guiding this study results from literature reviews and empirical studies, coupled with the characteristics proposed in Mintzberg's configuration theory . The strSeveral theoretical models can be applied to study EHR adoption by healthcare professionals. Most of them consist in frameworks developed in other scientific fields, such as psychology, education, and sociology. In this study, factors that are hypothesised to influence EHR adoption by individual healthcare professionals are borrowed from a set of validated theoretical frameworks.Among those frameworks, the Diffusion of Innovation (DOI) has received much attention in the study of ICT adoption in healthcare . This moThe Technology Acceptance Model (TAM)  was specThe TAM was specifically developed in the field of ICT adoption and it proposes a set of constructs that can be measured among various groups of users . One limThese two models are presented jointly because the Theory of Planned Behaviour (TPB) ,64 constHowever, some behaviour might not be totally under volitional control, which means that they require specific resources, skills, or opportunities for an individual in order to perform them. Therefore, the TPB ,64 propoi.e., the frequency of its occurrence.Another model that has been used to understand acceptance behaviours with respect to ICT is the Theory of Interpersonal Behaviour (TIB) . In esseAccording to the TIB, the behavioural intention is formed by attitudinal normative beliefs. Attitudinal beliefs are formed by affective (affect) and cognitive (perceived consequences) dimensions. Affect represents an emotional state that the performance of a given behaviour evokes for an individual, whereas perceived consequences refer to the cognitive evaluation of the probable consequences of the behaviour. The TIB also incorporates two normative dimensions: social and personal norms. Social norms are composed by normative and role beliefs. Normative beliefs consist of the internalisation by an individual of referent people or groups' opinion about the realisation of the behaviour, whereas role beliefs reflect the extent to which an individual thinks someone of his or her age, gender and social position should or should not behave. The personal normative construct of the TIB is formed by personal normative belief, described as the feeling of personal obligation regarding the performance of a given behaviour, and self-identity, which refers to the degree of congruence between the individual's perception of self and the characteristics he or she associates with the realisation of the behaviour.Compared to other intention-behaviour models, the TIB has a wider scope because it also considers cultural, social, and moral factors. The TIB was found to be a successful model to explain healthcare professionals' intention to perform clinical behaviours . The TIBA prospective cohort study will be used to identify the individual and organisational determinants of EHR adoption by healthcare professionals. This prospective design will follow study participants over time to verify how the determinants of EHR adoption evolve and to allow testing the predictive validity of the theoretical framework. Using Hierarchical Linear Model (HLM), the study will take into account the nested structure of data . If no sCapitale Nationale Health Region . This health region is divided into four Health and Social Services Centres (CSSS) that integrate a total of 78 units. The health region also includes 17 accredited Family Physicians Groups (FMGs). For the purpose of the study, a healthcare organisation is defined as a unit from one of the CSSS  or a FMG. HCOs targeted by the EHR project will be categorised in strata according to their size, mission, location, and nurses/physicians ratio. HCO in each stratum will be randomly ordered by an independent biostatistician. HCOs will be contacted and invited to participate in the study according to this random order until 60% of the HCO in each stratum have been recruited. If recruitment target of 60% is achieved in each stratum, a total of 50 HCO will be recruited. A sample of 50 clusters at the healthcare organisation level is usually considered as sufficient for longitudinal multilevel analyses [A stratified random sample of 50 healthcare organisations (HCOs) will be selected in the analyses .In each HCO cluster, we aim to recruit a minimum of 15 and a maximum of 30 health professionals according to the size of the HCO. The sampling method will be similar to that used for HCO level. Potential participants in each HCO will be randomly stratified according to healthcare profession (physician and nurses). Recruitment will take into account the distribution of healthcare professionals in each HCO. We estimate a recruitment rate of 50% per HCO which corresponds to that of our preliminary work and to similar studies . When thThe HCO questionnaire measures structural and contextual organisational factors and is adapted from the literature ,52 as weAlthough adoption is considered as the key indicator of the success of EHR implementation by decision makers, no specific measure of this behaviour has been proposed ,84. It iet al. [For the development of psychosocial questionnaires, Davidson et al.  recommenet al. . This meet al.  and the et al. ,64. To dAt the organisational level, the HCO questionnaire will be administered by telephone at time I to two key informants, representing the managerial  and the professional  decision makers of each of the 50 organisations sampled. Key informants have been widely used in sociology, management, and marketing studies to obtain data on organisational variables ,92. Intei.e., laboratory tests, prescription database, digital imagery, and electronic clinical note). Because the sample is considered to be relatively stable, we do not anticipate major losses in follow-up. Our conservative sampling also secures a sufficient number of individual respondents by organisational units. Based on the specific adoption behaviours identified through the Delphi study, we will calculate a composite EHR adoption score by summing the score of each adoption behaviour measured, that will correspond to adoption patterns [At the individual level, individual questionnaires will be distributed at Time I to participating health professionals within each participating organisation. A study code will be assigned to each participant to facilitate follow up. The list of participants' names and codes will be kept confidential. A package containing a letter from the organisation's direction, a leaflet presenting the study, the study questionnaire, a consent form, and a reply envelope will be distributed to participants. At Time II , a second questionnaire will be distributed to the same participants to assess their current use of EHR. The second questionnaire will cover the same items as at Time I, but will also measure the frequency of use of the various components integrated in the EHR  predict EHR adoption by healthcare professionals.2), and the omega-squared (ώ2) will be calculated. Then, the relevance of applying multilevel modelling to our data will be assessed by testing an unconditional or null model in which no predictors are specified. This allows verifying if significant variations in the dependant variable are present across healthcare organisations. If appropriate, a multilevel regression model [Descriptive analyses of the data at each level  will first be conducted to explore the distribution of socio-demographic and theoretical data. Statistics that are used to assess the reliability of individual data aggregated at group level in hierarchical models, such as the intra-class correlation (ICC1 and ICC2), the eta-squared (ηon model  will be on model . If endoon model . This soThe project has been approved by the ethics committee of the CHUQ Research Centre. Because the study population does not include patients, it is not required to seek ethics approval from other participating healthcare organisations. However, organisations solicited for participating in the project will be informed of the ethical aspects of the research and will receive copies of the research protocol and the ethics approval in order to ensure their informed decision to participate. The questionnaire for healthcare professionals will contain a unique code to identify study participants in order to facilitate follow-up. The list linking nominal information of participants to their study code will be kept in an electronic document protected by a password that will only be known by the principal investigator and the project coordinator. Other questionnaires and research materials will be anonymous.This study will provide unique knowledge on the most important factors to consider in the design of strategies for improving EHR adoption by healthcare professionals. As such, it will identify organisational and individual determinants that are key elements to the success of the ambitious interoperable EHR project promoted by the Canadian healthcare system. This project will be the first, to the best of our knowledge, to assess the unique contribution of organisational and individual factors, as well as their interactions, to the successful implementation of EHR. Moreover, the study will imply a wide range of healthcare settings to ensure greater generalisability of the results. These results will be particularly relevant and timely for decision makers who currently face the challenge of implementing EHR in the Canadian healthcare system. This study will apply a novel approach to assess adoption behaviour that is likely to be transferable to other settings. Furthermore, this research addresses some of the most important issues in the field of knowledge transfer and implementation science by proposing a theory-based, multilevel prospective longitudinal study that represents a major contribution to the field . This prThe authors declare that they have no competing interests.All authors collectively drafted the research protocol and approved the final manuscript. MPG is its guarantor.