Rowlandius potiguar (Schizomida: Hubbardiidae) in the laboratory. The specimens were maintained in a terrarium, in an aphotic room, with temperature and humidity levels similar to the cave of origin. We used the focal-animal and ad libitum methods to describe behavior with qualitative and quantitative evaluations of behavioral acts. We witnessed nineteen behavioral acts, which is considered representative for observations in captivity. Two activity periods were observed: between 10 a.m. and 4 p.m. and between 10 p.m. and 4 a.m., characterizing an ultradian rhythm. In adaptive terms, this condition may be important for population maintenance in oligotrophic environments such as caverns. Necrophagy and cannibalism were also registered and could have been selected in the subterranean environment due to oligotrophy. The observation of rare and unprecedented behavior in this group, as well as the presence of rhythmicity in activity patterns, contribute to a better understanding of the ecological aspects of the species of this still little known Order.Although organisms of the order Schizomida are not widely distributed in caves throughout the world, they can, eventually, be abundant in certain regions, becoming a major faunal element in some caves. The majority of works on this order includes species descriptions, with rare references to behavioral aspects. As such, the present study describes the behavioral repertoire, and the activity and feeding periods of  The cave environment presents peculiar characteristics when compared to the epigean environment. Among them stand out the permanent absence of light and the tendency towards the stability of environmental conditions, such as temperature and humidity Strinatia brevipennis, from a cave in Brazil, in which alterations in the expression pattern of the circadian rhythm were detected Studies show that many species that inhabit the subterranean environment exhibit behavior different from those who live in the epigean. Hoenen and Gnaspini Organisms of the order Schizomida are relatively frequent in the edaphic fauna of tropical and subtropical forests, generally being located in the upper soil layer (0–7 cm), among decaying leaves and twigs The order Schizomida is currently represented by 258 species in 46 genera Most articles on the order Schizomida are made up of species descriptions. There are some references to behavioral aspects, mainly feeding and reproduction, but there still are few references about behaviors exhibited by free ranging specimens  of this order Rowlandius potiguar (Schizomida: Hubbardiidae) in the laboratory. The period of activity and feeding behavior of this species were also described.Since the knowledge of the spontaneous behavior of individuals in order Schizomida is still incipient, especially when considering cave populations, the present study aimed to describe the behavioral repertoire of Rowlandius potiguar, is distributed in 20 carbonate caves in the western area of the state of Rio Grande do Norte, Brazil The species Rowlandius potiguar  was verified in this cave. Field collecting permits were issued to R.L. Ferreira by SISBIO/CECAV (license n. 14783-1). Cave geographic coordinates were obtained through CECAV's database (available at http://www.icmbio.gov.br/cecav/downloads/mapas.html).Specimens of the study were collected in the “Gruta do Geílson” limestone cave, located in the municipality of Felipe Guerra, Rio Grande do Norte, northeastern Brazil .This cave is located in the karst area of the Apodi Group For this study, 54 individuals were individually captured in three collection events: July 2008 (12 ind.), January 2009 (8 ind.) and July 2009 (34 ind.). All specimens were collected in the second hall of the cavity in an area with permanent absence of light and with high humidity. In 3 days, the specimens were transported to the Cave Ecology laboratory at the Federal University of Lavras, Lavras, Minas Gerais, Brazil. During transportation the organisms were individually maintained in plastic containers with moist paper towels, placed into Styrofoam boxes to avoid desiccation and sudden temperature changes.In the laboratory, the specimens were housed in a terrarium in a room with constant darkness . The terThe terrarium was modified so as to maintain the temperature at about 27°C and humidity at around 90% (conditions similar to those observed in the cave) . On the For individual or quantitative evaluations the specimens were held in individual transparent containers . The base of the inner portion of these containers was coated by sandy substrate and the opening was closed with moist cotton. Humidity and temperature were maintained simulating the conditions prevalent in the original habitat of the species (90% and 27°C respectively). Specimens were kept in a room with permanent absence of light.The feeding of the specimens was performed every two weeks by offering prey such as springtails and mites, which were captured and placed still alive in the individual containers and in the terrarium. In addition, the specimens also fed on small dipterans, symphylans, aphids and small millipedes, which were offered on some occasions.ad libitum observation method The measurements were expressed as the amount of time (seconds) that the analyzed organism remained in that behavior. As a complementary method for the observation of group behavior (for the specimens placed in the terrarium) the During the observations a red light was utilized to minimize the effects of artificial illumination on the animals  Observations were made daily for two hours during two weeks (August 2008), describing the behavioral repertoire of the individuals. The quantification considered all behavioral acts shown, even those seen only once in a single individual.The quantitative observations were conducted between August 2008 and November 2009. These observations were individualized, each individual being observed for a period of two hours daily , taking turns with the times of day at which the same individual was observed in order to total a 24 hour observation per individual. Thus, the different behavior could be quantified in each individual during the morning, afternoon and evening shifts. We measure the time spent in each behavior by means of a stopwatch.During individual observations, in addition to quantifying the duration of each behavioral act, the description of the feeding process was also conducted. Eating behavior was assessed immediately after the release of the prey inside each individual containers. Every movement made by the individual after the placement of the prey into the container was described (but not quantified).The activity pattern of the specimens was determined as the sum of the values of all behaviors observed and measured for all individuals, excluding only the periods of immobility, during individual quantitative observations. We thus defined the active behavioral pattern through the percentage value of the activities measured during the observation periods. Between groups, we compared the behavioral patterns for nine females and six juveniles. Males were not evaluated due to the low number sampled (two specimens). To statistically test the activity pattern found, the periods of greater and lesser activity were grouped. The data of all individuals for each observation period (in seconds) were transformed into log x+1 and compared by the t test. The t test was also used to assess differences in activity patterns between females and juveniles. These analysis were carried out using the BioEstat 5.0 statistical software We used linear regression among the different behavioral acts performed by the specimens in order to demonstrate how much each behavioral act influenced the occurrence of another behavior. This statistical analysis was conducted using R software model 2.15.3 Rowlandius potiguar, which were grouped into six categories , the others having died before the end of the cycle of observations. No male completed the 24h series, so that the data relating to this group is restricted. Females showed longer survival in captivity, living up to 378 days (mean - ± SD  =  242±105 days), followed by juveniles (207±111 days). The male with longest time under laboratory conditions survived only 28 days (14±8 days).The most frequent behavior was to remain motionless . The malThe predatory and feeding behavior of this species is characterized by a set of behavioral acts. The potential prey is readily perceived, by mechanisms not yet elucidated, immediately after its introduction into the enclosure of the specimens, but apparently the anteniforme pair of legs (the first pair of legs) is of great importance in this process, since the movement of the pair intensifies in these situations. When getting closer to the prey, the specimen poses in an attack/defense position, remaining motionless for a few seconds with the anteniforme legs and pedipalps open. If the prey escapes, a new search is performed on the substrate, when prey remains motionless, the specimens conduct their assault. The attacks are performed successively until successful or until the prey is no longer perceived in the environment.In the immobility period preceding the assault, the organisms apparently evaluate the viability of capturing prey. If it has a larger size than the individual, there is no attack. However, if its size is favorable to attack , there is an abrupt and quick approach, using the pedipalps and the pair of anteniforme legs to immobilize the prey. After capture, the prey begins to be torn into small fragments via the chelicerae.The prey offered were generally smaller than the schizomida, reaching a maximum of 75% of its body size. Only for juvenile individuals was this percentage close to 100% and, on these occasions, such specimens invested in trying to catch the smaller prey, when present.During feeding, the specimens perform movements with the pedipalps to change the orientation of the prey in relation to the chelicerae. The pairs of Legs 3 and 4 remain motionless, serving to support and lift. The second pair, in particular, is most often used to manipulate the food, while anteniforme pair (Pair 1) remains on the substrate most of the time and is used for faster and more complex movements such as changing the orientation of the prey in relation to the body of the specimen. At the end of the feeding process, it is generally not possible to see the remains.After feeding, the specimens clean their pedipalps, taking them to the chelicerae, rubbing them against each other or by using the second pair of legs. The anteniforme legs and the first locomotor pair (second pair of legs) are also taken up to the chelicerae to be cleaned. The feeding process is followed by long periods of immobility in which activity can not be observed for days.At a certain opportunity, necrophagy was observed to occur when a specimen fed on a dead mosquito provided in the container. In the terrarium, we observed the occurrence of cannibalism of adult females on juvenile individuals on two occasions.The specimens had higher peak activity between 10 a.m. –12 p.m., followed by secondary peaks between 2 p.m. – 4 p.m., 10 p.m.- midnight, midnight - 2 a.m. and 2 a.m.- 4 a.m. . The values found show two groups of high activity periods: the first, between 10 a.m and 4 p.m. and the other between 10 p.m and 4 a.m. The two groups of high activity were significantly different from periods of low activity (t = 2.099 and p = 0.04). Females and juveniles, when analyzed separately, showed a distinct pattern . FemalesWe observed significant and positive relationships among the more frequent active behaviors , demonstSpecimens often buried themselves under the terrarium substrate and in some individual subterranean shelters digged by themselves . These wSchizomus vinei. Although Rowland Trithyreus pentapeltis couple, addressing offspring behavior and juvenile development, spontaneous, dietary or those behaviors related to the pace of activities were not considered. Thus, it is impossible to perform the comparison of the behavioral repertoire exhibited by specimens of Rowlandius potiguar with other species of that order.Works regarding the biology of the species of the order Schizomida are infrequent in the literature Tityus serrulatus), the low number of behavioral acts was related to the presence of parthenogenetic species, which were investigated solely from the female behavior point of view Paratemnoides nidificator), the large behavioral repertoire is due to the social organization of the group, communication being the most representative behavior category, with 36 different behaviors based on the variations of the pedipalp vibrations Other groups of arachnids exhibit wide variation in the number of behavioral acts. Ethograms made for species of Opiliones Trithyreus pentapeltis couple, Rowland noted that the female survived for 167 days, while the male exceeded that number (the exact period is not described). The life span of juvenile individuals was not measured accurately, however, according to Rowland, the sub-adult period seems to be between two and three years Schizomus vinei, which survived up to 196 days. The low survival rate of male individuals in this study may be related to the reproductive period, as noted by Eickstedt Phoneutria. Generally, as adults, the male specimens of this group die after the last copulation due to being quite debilitated The survival periods presented for specimens of this genus in the laboratory differ from those reported by Rowland The behavior of remaining motionless was frequent in individuals in captivity. However, there are differences in this behavior in relation to age and sex of the individuals observed. The long time spent motionless and low locomotion activity in adult males may be a result of the low number of individuals and times analyzed for this group. It can also be related to the direction of their energy towards reproduction, avoiding spending it on other activities, since, as observed in this study, the survival time for adult males was low. Furthermore, the specimens studied may, eventually, be territorialist, thus justifying the low mobility of adult males, because all individuals observed in each terrarium occupied each shelter alone. Perhaps repugnatory or anal glands, which are ventrally located, can be used to maintain territoriality.Moreover, the higher movement activity in females may be related to the necessity to inspect large areas in search of prey or even seeking males for breeding, since they are rarer, andin many species, even unknown Rowlandius potiguar apparently is an active predator, it will search for prey, as evidenced by observations in captivity. The act of catching prey proved complex in relation to the recognition of prey , and in this period there is a risk of the prey not being captured, or even being a potential predator. Thus, for females and juveniles, the locomotion activities for seeking prey may become more intense because they are less robust, which may hinder encountering more compatible prey.R. potiguarThe higher manifestation of substrate groping and cleaning and movement of pedipalp behaviors was expected, since the activity of the studied specimens show high correlation among the active behavioral acts. The correlation of these acts suggests that, during exploration of the environment, cleaning activities are necessary for a better perception of the environment. Small openings, called uropygid pores, of unknown function, have been described in Schizomus vinei ranged from 10% to 100% of the total length of the Schizomida itself. In the present study, the attacks on smaller prey probably favored the predation process, particularly for juvenile specimens, since smaller prey exhibit lower defense and predators of larger instars have higher predation capacity The eating habits of schizomidas are little known The manner in which the specimens captured and manipulated the prey was similar to that described in other studies The fast movements presented by the studied individuals have an important role in the predation process. It can be inferred that the successful capture of collembolas depended on the speed at which the specimen effected the attack and the distance between predator and prey.Cannibalism in the order Schizomida has already been reported Loxosceles, a feeding preference for dead prey. In the analysis, for the three varieties of live and dead prey offered, all the preference for the dead was more than 81%. For Schizomida, such a situation would be ecologically important, since opportunists and necrophages have an advantage over the most selective predators, because their feeding needs are more easily met The necrophagy observed in a specimen under study had not yet been reported for Schizomida. However, Sandidge The activity pattern values found suggest the presence of an activity cycle every 12 hours, characterizing an ultradian rhythm, which denotes biological activities that occur in physiological cycles of 20 hours or less Lycosa tarentula) in cycles of continuous darkness R. potiguar is an adaptive response to the permanent aphotic condition of the cave in which this population is established. In epigean populations, which are subject to variations in light levels and periods, different activity cycles may eventually occur.The ultradian rhythmicity in activity patterns were also observed in spiders of the family Lycosidae (The cave environment is little studied from the chronobiological viewpoint, especially when considering the artropods The difference between the activity periods found between females and juveniles could be, because the latter, despite the presence of rhythmic oscillations of the clock, do not observe the expression of biological rhythms due to the immaturity of the effector systems involved Tityus serrulatus in captivity R. potiguar.During the experiment, a significant decrease in the time spent to perform the active behavioral acts throughout the observation time was perceived . The samRowlandius has the ability to dig its own nest in captivity. Such behavior, however, is apparently rare in natural environments in which the organisms prefer to shelter themselves among the decaying leaves and branches, or humus, or in termite mounds and rotten logs It was observed that this species of The behavioral study of cave species is important for a better understanding of the influence of the environmental stability and absence of light on these organisms. For Schizomida such research is even more important since few studies highlight the biological aspects of this order. The observation of rare and unprecedented behavior in this group, such as cannibalism and necrophagy, as well as the presence of ultradian rhythmicity in the activity patterns, contribute to a better understanding of the ecological aspects related to organisms of this Order.


Earthquakes are renowned as being amongst the most dangerous and destructive types of natural disasters. Iran, a developing country in Asia, is prone to earthquakes and is ranked as one of the most vulnerable countries in the world in this respect. The medical response in disasters is accompanied by managerial, logistic, technical, and medical challenges being also the case in the Bam earthquake in Iran. Our objective was to explore the medical response to the Bam earthquake with specific emphasis on pre-hospital medical management during the first days.The study was performed in 2008; an interview based qualitative study using content analysis. We conducted nineteen interviews with experts and managers responsible for responding to the Bam earthquake, including pre-hospital emergency medical services, the Red Crescent, and Universities of Medical Sciences. The selection of participants was determined by using a purposeful sampling method. Sample size was given by data saturation.The pre-hospital medical service was divided into three categories; triage, emergency medical care and transportation, each category in turn was identified into facilitators and obstacles. The obstacles identified were absence of a structured disaster plan, absence of standardized medical teams, and shortage of resources. The army and skilled medical volunteers were identified as facilitators.The most compelling, and at the same time amenable obstacle, was the lack of a disaster management plan. It was evident that implementing a comprehensive plan would not only save lives but decrease suffering and enable an effective praxis of the available resources at pre-hospital and hospital levels. Earthquakes are renowned as being amongst the most dangerous and destructive types of natural disasters known. More than one million earthquakes occur worldwide each year. Major earthquakes occur on average once every three years . On a glMore than 90% of all the deaths caused by natural disasters occur in developing and underdeveloped countries . Iran, aAn earthquake with a magnitude of 6.7 on the Richter scale hit the city of Bam in Iran Figure  [7]. TheHealth services were rendered as non-functional Table  13]. Mo. Mo13]. The medical response in disasters is normally accompanied by managerial, logistic, technical, and medical challenges -19 whichOur aim was to identify obstacles and facilitators in pre-hospital medical response focusing on analyzing the organizational preparedness. We believe that the results can be used in designing an appropriate disaster management plan for both pre-hospital and the hospital services.The study was performed in 2008 on an interview based qualitative study using content analysis ,23. We uWe conducted nineteen interviews with experts and managers of Iran's emergency and disaster medicine system. The participants were involved in the medical response to the Bam earthquake, including pre-hospital emergency medical services, the Red Crescent, and Universities of Medical Sciences. They had more than 5-year experience in disaster medicine and had participated in previous disasters.The selection of participants was determined using a purposeful sampling method. The participants were included until saturation of each concept was reached and further data collection failed to contribute additional information. Sample size was given by data saturation.Each interview lasted between 50 and 90 minutes. The interviews were conducted in Persian by the same interviewer, transcribed verbatim and then translated to English. Content analysis was performed on the data written in Persian, before translation.The interview guide included a list of general questions used as a tool for initiating the interviews. Complementary probe questions were added when needed and, data collection and content analysis identified ideas, as is in accordance with the methodology.During the open coding phase, all the interviews were read several times, and key words and phrases, incidents and facts in the text were noted. Primary codes were extracted. The codes and data were compared for similarities and differences.Categories and sub-categories were developed. From the first interview, a preliminary set of codes, categories and sub-categories was created. These codes were described as the results -24. In aData validation was performed through in-depth prolonged engagement with the data -24. ThisEthical clearance of the study was obtained from the Natural Disaster Research Institute in Iran. Informed consent was obtained and all participants were informed that they could refuse to participate or withdraw from the study at any time.The mean age of the participants was 43.5; well-educated in both health and medical sciences Table .The pre-hospital medical services were divided into three categories; triage, treatment  and transportation, and for each category in turn we had identified facilitators and obstacles Table ."Triage wasn't conducted during the medical response to the earthquake. Most of the casualties that were transported to nearby cities or to the airport only had minor injuries."The most important factor which affected the performance and workload of the medical services was the absence of triage. This was observed both at the pre-hospital and hospital level. The casualties were transferred to the airport or hospitals in nearby cities without being triaged. The lack of triage had detrimental consequences for both treatment and transportation, as well as the workload for the responding emergency medical services. For instance, a participant said "With the lack of a disaster management plan and triage procedures, as well as incorrect policies, these were the main reasons that triage was not performed."The absence of a structured procedure and organized teams were the reasons for the lack of triage. In fact, there was no standardized operational plan for performing triage at the scene whatsoever. The lack of material resources was another contributing factor limiting the execution of triage. This included the lack of markers, tags, data forms, and basic medical equipment. Consequently, relatives and responders took the casualties directly to the airport or transferred them to hospitals at of nearby cities. A manager explained that "Triage was missed due to the lack of both triage teams and resources. There was no organized triage team on the scene. There was also a complete and apparent lack of essential triage resources during the first day."Groups of medical personnel, from the army and medically trained volunteers from the universities, were transferred to the earthquake area by the military air force within a few hours of locating the earthquake. Some of them were medical doctors, including surgeons and emergency medicine physicians. The airport was full of casualties needing medical attention and there was a continuous flow of earthquake victims being transported from the city to the airport. The medical personnel stayed at the airport and initiated medical treatment."When we arrived in Bam, as individual medical officers and not part of a specific team, and without any pre-packed medical resources, we were struck by the large number of casualties at the airport." reported by a medical professional.These specialists weren't planned to be part of the standardized emergency medical teams, and were not equipped with the necessary medical equipment or provided with resources to enable triage. However, they organized themselves as a response team and used the available resources and facilities to help the casualties at the airport as much as possible under the given circumstances. "We organized the personnel as a team with the objective of conducting triage and giving life saving interventions on site at the airport. However, due to the shortage of resources, security and managerial problems, our system wasn't effective enough." an expert said.Developing a triage system at the airport was the most important activity providing by this team. The airport was the only place where the earthquake victims were triaged, albeit in a limited fashion, without standardization or overall coordination and with a delayed start. They divided the airport waiting rooms into a few separate areas. They evaluated most of the casualties before further transport with airplanes and used the available resources for marking the casualties as triage groups. In addition, life saving medical care was administered. "The absence of triage on scene made us perform primary triage at the airport. Performing triage decreased the overall workload for the medical service and transport organizations at all levels."Another participant reported that "All of the casualties arrived at the airport without first having medical attention before transportation from the earthquake site. Only, a few casualties had an intravenous line or wound dressings. In fact, the majority of the casualties received medical attention at the receiving hospitals."Emergency medical care on scene is life saving. Participants explain that this critical function was missed at the scene and basically all of the casualties were transferred to other cities without receiving initial medical attention. A medical doctor working at the airport said that "We tried to provide on scene medical care for the casualties before taking them to the hospitals but it wasn't possible due to the lack of plan for how the medical system was supposed to manage the large number of casualties in a city structurally destroyed by the earthquake."However, the absence of a disaster management plan was the main reason for the lack of treatment. For instance, a manager said that One of the main shortcomings in Iran's medical disaster management system, with respect to the Bam earthquake, was the lack of standardized disaster medical teams."A disaster management plan along with emergency medical teams is the most important functions in order to guarantee appropriate medical care in a disaster area. During the Bam earthquake, a large number of disaster medical assistance teams were needed in order to provide emergency medical care. This need was not met. An expert explained that "Due to the lack of structured medical teams, untrained medical volunteers that were involved in rescuing and caring for casualties. They were not organized as teams. They were like small islands and their performance was not good enough. Actually, we had to support them with medical and general equipment."Another expert mentioned that "The interviewees emphasized the shortage of resources on the scene. Medical teams did not have enough equipment during the acute phase, and the destruction of all medical facilities made the situation worse. Consequently, medical services ceased during the first night. This, along with the cold weather, worsened the medical condition for the casualties."We had a considerable shortage of resources for providing medical services at the earthquake area during the first days."A manager said that Working at the earthquake area amongst extensive destruction, a large number of casualties, with too few medical responders and with a lack of resources was difficult. As a result, medical services stopped during the first night. Besides, it was very cold and most of victims were exposed and could not keep warm. Consequently, some of them died due to exposure."And another added that "Military medical teams were one of the first teams that arrived at the earthquake site. They supported the pre-hospital medical system in every way, providing medical services, equipment and personnel."Experienced and trained medical responders had enhanced the emergency medical response performance. Several organizations mobilized with the aim of reducing the impact of the Bam earthquake. Especially the army and the Red Crescent assisted the EMS. They sent medical teams to the scene, who participated in the search for buried victims, and contributed to the transportation of casualties. These teams included trained medical staff with experience from previous mass casualties, along with medical supplies. The army and the Red Crescent also provided logistics support. "Iran's Red Crescent sent many ambulances and medical teams to the earthquake area. They conducted rescue operations, provided basic medical care for the casualties, and transported them to the airport or nearby cities as required.""Many volunteers from the Universities of Medical Sciences arrived at the earthquake area in addition to the above mentioned organizations. Some of whom were well educated and had previous experience of disasters. Volunteers with advanced medical degrees could, partly, compensate for a lack of standardized medical teams.The presence of medically trained volunteers helped the medical system to care for thousands of casualties on scene, despite them not being organized as standardized teams" according to one of the interviewee.The medical response could have been different had there been a disaster management plan, an organization for coordinating the rescue efforts and sufficient resource. "if the managers had organized the medical volunteers as coordinated teams, the medical services could have been conducted more effectively."Another study participant said that "Other responders were international emergency medical teams. These teams arrived late, when the earthquake site was cleared of trauma victims, hence despite having structured teams their contribution was insignificant.There was no operational plan nor were there procedures for transportation. All decisions were made on the spur of the moment."The transportation of casualties to medical centres is an essential function in disaster response. The government decided to transfer all casualties to other cities since the Bam earthquake had destroyed all the local medical facilities. The lack of a disaster plan affected these operations also. In fact, there was no coordinated transportation plan at any level, neither was there an organization or a team responsible for the transportation of victims. At times, casualties were airlifted from the earthquake area without coordination with the receiving medical system. A participant mentioned ""Casualties were, in some cases, transferred from the earthquake area to a specific city, and because of the inability to admit the casualties, they were referred to yet a second city" according to another interviewee.The roads were completely congested, to the extent that evacuating the casualties by road way was impossible."The lack of a coordinated plan for transportation of the casualties resulted in traffic chaos and a stop in air transportation. The roads were not controlled by the police and became blocked by vehicles. Additionally all transportation from Bam to the airport and the further evacuation by air was stopped during the first night because of darkness, very cold weather and lack of safety. A participant reported "Only a few hours after the arrival of the first response teams, the evacuation by air was stopped" according to another participant."Furthermore, there were no standardized transportation methods, neither for ground vehicles nor by air.There were, also, no standard protocols for evacuation, a shortage of transportation vehicles and trained medical personnel. There was a long delay in initiating the evacuation which resulted in a disorganised evacuation of the earthquake casualties. This may have increased the mortality and the long term medical complications, e.g. spinal injury.Since the arrival of rescue workers was delayed, some untrained response workers and laypeople began evacuating the casualties to nearby cities in private vehicles, without taking medical considerations.""there weren't sufficient resources, equipment or ambulances. As a result, the casualties were evacuated without medical considerations."Another expert said "Victims transported by air must be done based on standardized protocols. Unfortunately many casualties were left on the floor of the airplanes without proper fixation or a plan for medical care during the flight." as mentioned by another interviewee."There was no control or security system at the airport."Furthermore, the absence of a prioritization for evacuation of the individual casualties was a problem. There were no rules or plans for the evacuation of casualties from the city to the airport, and from there on to the receiving cities. All casualties, both mild and severe, as well as relatives, were transported to the receiving cities, without a priority for the severe injured. This resulted in prolonged waiting times for all casualties involved. "medical priority was often missed while evacuating the casualties. Many casualties with mild or even without injuries were transported to other cities, while some casualties with severe injuries were still waiting for evacuation."Another participant reported that "The evacuation of thousands of victims from Bam in two days was one of largest rescue operations ever performed in the history of Iran. Ground transportation was the most common means of transporting victims on the first day and by air on the second. In fact, there were two evacuation waves. A small number of casualties were evacuated on the first day. The second wave started in the early morning on the second day and consisted of casualties evacuated mainly by air.It was the air force's responsibility, along with the air transport organization, to provide the evacuation by air. In addition they carried managers, medical teams and equipment to the earthquake area."The air force managed to reopen the airport, which had been damaged by the earthquake, and more than 10,000 casualties were evacuated within 24 hours through this airport."A participant said "The air force and air transport organization concentrated all efforts on establishing a reliable evacuation path by air from Bam to the rest of the country."Another participant added that "Several thousand casualties had been taken to Tehran's airport. The Air force established an air bridge between the airport and other large hospitals."This situation was also seen in other cities, especially in the capital, Tehran. A manager quoted In this article we focused on the pre-hospital issues of the early response phase to the Bam earthquake. The key elements in the pre-hospital medical response to disasters are correct triage, immediate treatment and in giving priorities for evacuation , which oDuring the medical response to a disaster, triage is needed at three locations: (1) on scene; (2) in the treatment and resuscitation area; and (3) at the receiving hospital .The current study emphasized that the triage process was problematic, not performed on scene but was to a certain extent at the airport. All previous studies from the Bam earthquake ,14,26, wReports from other earthquakes show divergent results with respect to triage. During the tsunami in Thailand in 2004, field triage was performed and 70% of the victims were primarily treated in the field or triaged to emergency healthcare centres . Yasin, In summary, the lack of triage could affect medical response at all levels. In other disasters, triage has been performed to a varying extent. With the current medical response organization in Iran, hospitals should expect to receive many non-triaged casualties in the event of an earthquake. Therefore, some of the resources will be "unnecessarily" used for low priority cases, instead of the severely injured casualties. Triage is a vital issue in a disaster plan.There was a lack of on site emergency medical treatment. This finding was supported by other studies ,11,14,21Reports from other earthquakes show a similar situation worldwide, that medical response was inadequate on site, and most of the casualties were transported away from the earthquake area without initial medial treatment -30.In summary, there was lack of immediate and adequate emergency medical care during the Bam earthquake. This could be one of the reasons for the high death toll in the Bam earthquake. Also, it is to be expected that the receiving hospitals not only receive non-triaged casualties but also casualties not having received primary medical treatment in the field. This lack of pre-hospital care will necessitate a large consumption of medical resources and strategic facilities to surge capacity. This point must also be considered in disaster planning.This study shows that the overall effort of transporting victims was uncoordinated and insufficient. However, an air bridge did provide a means of rapid transportation for earthquake victims. Approximately 12,000 injured people were evacuated within 48-72 hours using civil and military aircrafts, road transportation and helicopters ,32.These findings are supported by other studies . FurtherOur observation that traffic jams inhibited transportation was confirmed by other researchers. Most of the roads leading both to and from Bam were blocked due to the rapid influx of rescue workers and by victims' relatives coming from neighbouring cities ,33.The effects of earthquakes on transportation are similar worldwide. For instance, on the first day after the Kobe earthquake in Japan in1995, only one person was transported by helicopter, and a total of 17 people were transported within the first 72 hours . The famWe conclude that ground transportation is always affected in major earthquakes. In addition, air transportation services are often unavailable. The failure of transportation of casualties could seriously affect the medical response. Therefore, the receiving hospitals could receive the casualties only after a long delay. Thus, enabling these hospitals to prepare for incoming casualties, and effectuate their disaster management plan if it exists.Timely and effective response to disasters requires an organized disaster response system which can provide the appropriate aid ,37,38.The lack of a disaster management plan was found to be the main obstacle in the pre-hospital medical management, with respect to triage, treatment, and transportation. Preparedness was not a priority for the Ministry of Health of Iran prior to the Bam earthquake, as explained by de Ville . The majThe lack of a disaster management plan has been recognized as a challenge worldwide regarding disaster response. The preparedness of the Ministry of Health in Pakistan was far from sufficient regarding the earthquake in 2005 . Since tOur results emphasized the necessity in developing a comprehensive and integrated disaster management plan for the medical system.Another obstacle in the pre-hospital medical response during the Bam earthquake was the absence of standardized disaster medical assistance teams (DMATs). DMATs defined as "mobile, trained medical teams that can be rapidly deployed during the acute phase of a disaster, provide medical treatment and relief activities, assisting in transferring casualties from disaster-affected areas to appropriate medical facilities" .The absence of standardized DMATs effects triage, treatment and transportation. Although, no previous studies have clearly analyzed the role of DMATs in the Bam earthquake, two studies point out that physicians and responders had not received training for aid, rescue, and treatment in critical conditions ,14.There was a similar situation during the earthquakes in Taiwan (1999), and Japan (1995). Only a small number of medical teams were able to provide critical care needed during these earthquakes. These experiences actually lead to the development of disaster medical assistance teams and the recognition of their importance ,34,39.Taking all of this into account is of great importance in establishing DMATs in Iran.The post-earthquake environment has normally very limited medical resources in the face of overwhelming needs . The shoReports from other earthquakes show a similar situation worldwide. de Ville explained that in spite of an overwhelming budget, after the tsunami in 2004, the external responses were burdened by serious shortcomings . Kohl etLimiting factors for the medical response during the Pakistan earthquake were operating space, equipment, supplies, and paramedical staff .Based on these findings, it is essential to develop an effective logistics system, and define its role as part of a comprehensive disaster management plan in order to provide the necessary medical resources in the earthquake area.The current study illustrated the comprehensive role of military teams, especially their participation in the airlifting of casualties and the provision of necessary resources.These results are supported by other studies ,26,32,33Similar experiences are reported in other disasters, e.g. the Tsunami in Thailand and Indonesia ,43, the As demonstrated, the army plays an important part in the early response to earthquakes. The army can be used in all parts of the medical response to an earthquake which should be taken into consideration when developing a comprehensive disaster management plan.Medical volunteers that came to the earthquake area, as part of a team or individually, during the early response to the earthquake were another facilitator. The first volunteer medical relief team consisted of 40 specialists, and arrived in the area a few hours after the event. These volunteers conducted the triage at the Bam airport . NumerouVolunteers played a crucial role in mass-casualty incidents . VolunteIn spite of the long delay, the role of international volunteer teams is important in helping the affected community. International organizations can assist the affected country by providing urgent medical services in proximity to the disaster area, thereby compensating for the shortages of medical facilities at national level .The number of volunteers is virtually unlimited in Iran, and medical volunteers are most willing to assist . OrganizThis study was based on interviews from the managers at Iran's emergency and disaster medicine system, who were responsible for the initial response to the Bam earthquake. We focused on the initial triage, treatment and transportation. Skilled medical volunteers and the military medical teams were facilitators of the early phase of the medical response. The main obstacles to the pre-hospital medical response were the lack of a disaster management plan, the absence of disaster medical assistance teams and the overall lack of resources. The most compelling, and at the same time amenable obstacle, was the lack of a disaster management plan. It is evident that implementing a comprehensive plan would not only save lives but decrease suffering and enable an effective usage of the available resources. Due to the crucial role of pre-hospital care system in disasters there is a need for further investigation based on the result of this study to develop strategies for improving the system.EMS: Emergency medical services; DMATs: Disaster medical assistance teamsThe authors declare that they have no competing interests.ARD was involved in the study conception and design, data collection, analysis, revision, editing and manuscript writing. HK was involved in the conception and design of study and took an active part in the data analysis and results interpretation. GO participated to the study conception and design, writing-up and finalization of the manuscript. MC contributed to analyze and interpret the data and to write the manuscript. LK participated to the study design, analysis and results interpretation and writing-up of the manuscript. All authors read and approved the final manuscript.


Very little is known about the attitudes and views that might underlie and explain the variation in occupational disability assessment behaviour between insurance physicians. In an earlier study we presented an adjusted ASE model  to identify the determinants of the disability assessment behaviour among insurance physicians. The research question of this study is how Attitude, Social norm, Self-efficacy and Intention shape the behaviour that insurance physicians themselves report with regard to the process (Behaviour: process) and content of the assessment (Behaviour: assessment) while taking account of Knowledge and Barriers.This study was based on 231 questionnaires filled in by insurance physicians, resulting into 48 scales and dimension scores. The number of variables was reduced by a separate estimation of each of the theoretical ASE constructs as a latent variable in a measurement model. The saved factor scores of these latent variables were treated as observed variables when we estimated a path model with Lisrel to confirm the ASE model. We estimated latent ASE constructs for most of the assigned scales and dimensions. All could be described and interpreted. We used these constructs to build a path model that showed a good fit.Contrary to our initial expectations, we did not find direct effects for Attitude on Intention and for Intention on self reported assessment behaviour in the model. This may well have been due to the operationalization of the concept of 'Intention'. We did, however, find that Attitude had a positive direct effect on Behaviour: process and Behaviour: Assessment and that Intention had a negative direct effect on Behaviour: process.A path model pointed to the existence of relationships between Attitude on the one hand and self-reported behaviour by insurance physicians with regard to process and content of occupational disability assessments on the other hand. In addition, Intention was only related to the self reported behaviour with regard to the process of occupational disability assessments. These findings provide some evidence of the relevance of the ASE model in this setting. Further research is needed to determine whether the ASE variables measured for insurance physicians are related to the real practice outcomes of occupational disability assessments. It is common knowledge that doctors tend to vary in their patient assessments and thus may draw different conclusions for the diagnosis and treatment of comparable cases -7. TargeIn this paper we examine assessments of work limitations of employees on long-term sick-leave by insurance physicians in the Netherlands. In the Netherlands, if you are partially or fully incapable of working after two years of illness, you may be eligible to receive a benefit under the Work and Income Act (WIA). The WIA succeeded the Disability Insurance Act (WAO) in January 2006. The Adapted Re-assessment Act (HERBO) was introduced in August 2004 for the reassessment of WAO benefits clients, i.e. the claimants (< 50 years), on the basis of new, stricter criteria that put the emphasis on the client's residual functional capacities. The WAO and WIA differ in the time of assessment. The WAO provides for assessments after one year of sick-leave, whereas the WIA provides for assessments after two years.Though it is generally acknowledged that variations will occur in the assessment of comparable cases, legislation, protocols and measures were introduced to narrow down this variation and promote uniformity .In order to assess a clients' work limitations the insurance physician starts with the functional limitations experienced by the client. These are tested for plausibility and internal and external consistency on the basis of the medical history and the actual ability of the client to perform tasks . The insurance physician bases his assessment on an interview and possibly a physical examination. He can obtain additional information by ordering additional tests or by contacting the GP, specialist or other healthcare provider, or the occupational physician (OP) who assessed the first two years of disability. The client's capacity for work is determined by reference to an instrument known as FAL . On this list the physician enters the client's scores for limitations and abilities. These findings serve as the input for the labour expert in determining the extent to which the client is able to earn income and able to work. As an instrument the FAL comes within the statutory framework of disability assessments in the Netherlands.The outcome of work limitation assessments by insurance physicians can be seen as the result of behaviour influenced by various factors, including behavioural determinants of the physicians in relation to the intended object of their assessment. Little is known of what considerations and views of insurance physicians may partly account for variation in the outcome of assessments. Therefore, a study was launched to add to the sparse knowledge in this field. First, Steenbeek et al.  developeDuring the first part of the present study a questionnaire was developed, based on literature study and interviews. It was completed by 231 insurance physicians. These formed the basis for the development of scales and dimensions that fitted with the concepts of the ASE model  - drafted the questionnaire for insurance physicians who perform disability assessments of long-term sick-listed employees ("clients"). At the start of 2008 UWV drew up a list of addresses of all insurance physicians working for the agency. In March 2008 UWV sent the questionnaire, together with a covering letter containing an invitation to participate in the research, to the home addresses of insurance physicians. A reminder was sent two weeks later. Not all the physicians belonged to our target group, but it was not possible to make a selection in the mailing. In total we wrote to 750 insurance physicians. Our estimate was that the target group consisted of 450 insurance physicians: insurance physicians actively employed by UWV in May 2008 who had performed work disability assessments of long-term sick-listed employees in 2007 or in preceding years. The criteria for inclusion were mentioned in the accompanying letter. The participants sent the completed questionnaire to TNO (Netherlands Organization for Applied Scientific Research). The response consisted of 231 questionnaires (estimated response approximately 51% of the target group).As we lacked the necessary data of the target population to do a full non-response analysis, we checked whether the group of participants (N = 231) was representative of the total population of insurance physicians working for UWV (N = approximately 900) in terms of age, gender, and working hours per week.As this study was based on a survey under (insurance) physicians only, approval by a Medical Ethical Commission was not necessary under Dutch law.In drawing up the questionnaire we used existing and newly developed concepts. These concepts were chosen on the basis of literature studies and four interviews with insurance physicians. In a pilot study two insurance physicians completed the questionnaire while thinking aloud in order to enable us to test whether the questions were correctly understood. Finally, two other insurance physicians were timed while they completed the questionnaire. For a detailed description of the questionnaire, the operationalization of the constructs of the ASE-model, the construction of measurements, and the imputation of missing values we refer to Steenbeek et al. . Below wadditive scale is constructed of numerical categories of items that can be meaningfully added. Some additive scales were formed on basis of already validated scales; other scales were formed after extracting factors and performing reliability analysis. For some items it was not possible to construct an additive scale. We grouped these items on a theoretical basis and used homogeneity analysis to analyse the dimensions behind these grouped items. The object scores of the dimensions that were meaningful and gave additional information were selected as variables. We call these variables 'dimensions'  is presented separately , working hours (week), years of experience as an insurance physician, assessments mainly under WIA or WAO or Wajong  legislation, client's industry/sector .Our original purpose was to estimate a structural equation model with latent variables for the theoretical constructs of the ASE model, using Lisrel . This prThe factor loadings were calculated as standardized coefficients. Factor scores are individual scores on basis of the factor loadings and the individual scores of the observed scales and dimensions on which a latent variable loads. The factor scores were treated as observed variables when we estimated a path model: a model with only observed variables.Before assessing the various measurement models, we normalized the scales and the dimensions by applying the normal score procedure , using PThe direction of the factor score of Social norm was reversed so that all factor scores of the ASE-constructs indicated a higher score on the meaning of the ASE-construct. Because it proved impossible to estimate a measurement model for the latent variable Knowledge alone (i.e. a not positive definite correlation matrix of measurement errors), we estimated the latent variable Knowledge and the latent variable Barriers in the same measurement model, because theoretically both play a role in the relationship between Intention and Behaviour in the ASE model. Furthermore, because the measurement model of Intention proved to be a Heywood case , i.e. a For the path model the background variables were defined as exogenous variables. The scale for Self-efficacy and the factor scores for the other seven ASE constructs were defined as endogenous variables. Because all variables, including the factor scores for the ASE-constructs, were treated as observed variables, we presented them as rectangles instead of ovals in the figures, according to the convention in path analysis . In the The mean age of the participants (N = 231) was about 51 years (sd = 7), about 41% were female, and they worked on average about 33 hours a week. The participants did not substantially differ from the population of insurance physicians (N = approximately 750) in this respect. About 86% was registered as insurance physician and about 15% was also registered in another medical speciality. The average number of performed assessments per week was about 9 (sd = 4). Insurance physicians had on average 16 years (sd = 8) of experience. We refer to Steenbeek et al.  for furtThe seven factor score variables were normally distributed (with mean = 0 and variance = 1) as was the scale for Self-efficacy . The factor loadings for all latent variables and the model fit parameters are listed in table A higher score for the latent variable 'Attitude' implied greater job satisfaction, a positive attitude towards the Work and Income (Capacity for Work) Act and the social benefits system, and a stronger belief in the development of one's own competence and support by management. In short, the variable points at a positive attitude towards both the profession and the system. Two dimensions were omitted from the measurement model: 'Recovery time: client still has some energy left after work' and 'Recovery time: good relationship with client'.A higher score for the latent variable 'Social norm' implies that the management is more based on quantity, production or outcomes and that more importance is attached to the opinion of the Employee Insurance Benefits Agency and employee representative bodies, fellow insurance physicians and society at large. In short, a higher score represents the insurance physicians who attach more importance to the opinion of others.Barriers and Knowledge were included as two separate latent variables in one measurement model because of technical reasons. The resulting outcome of this measurement model is in line with our allocation in the ASE model, i.e. both latent ASE-constructs loaded on items that were theoretically assigned to these ASE-constructs.A higher score for the latent variable 'Barriers' implies a respondent who experiences more work pressure, higher levels of emotional workload, less decision-making authority, higher levels of burnout, and less cooperation and input at office level. It also indicates that certain factors are experienced as restraints of the quality of the assessments, namely: supervisory insurance physicians, refresher courses and consultation, managers, legislation and reorganizations, and difficult groups of clients. In other words, a higher score for this variable means that the insurance physician is experiencing more barriers. Only the dimension 'Quality: influence of guidelines not adverse and production target not beneficial' was omitted from the model.A higher score for 'Knowledge' implies that the respondent gets sufficient information on the client from the OP, sufficient medical and other information from third parties and is more likely to find that the Reintegration Report supplements the medical information. All in all, the insurance physician feels that he has enough knowledge and information to perform the assessment. Only the dimension 'Insufficient medical information and knowledge' was omitted from the model.A higher score for 'Intention' implies that the respondent attaches more importance to: the promotion of recovery, resumption of work, self-reflection and re-integration, the relevance of capability, illness, disorders and handicaps in the assessment and, most of all, proper checks for the consistency of information on the daily activities and home situation of the client. To some extent this paints the professional attitude that one would expect from an insurance physician. We can therefore refer to it as 'professional intention'.A higher score for the latent variable 'Behaviour: process' indicates that the respondent shows higher levels of dedication, pays explicit attention to purpose and procedure during the interview, determines the order of the discussion topics and looks for a compromise in the event of a difference of opinion. A higher score for Behaviour: process therefore suggests an insurance physician who is eager, takes control and is prepared to strike a compromise with the client.The variables 'Interview: limitations not checked', 'Interview: respond to client', 'Conflict handling: engage in confrontation' and 'Conflict handling: play down differences' were omitted from the model.A higher score for the latent variable 'Behaviour: assessment' indicates that the respondent assigns permanent and full disability (in the Netherlands known as GBM) according to the guidelines, focuses less on the specific situation of the client (home situation and future) when drawing up the FAL , seldom or never consults a labour expert unless absolutely necessary, works with precision when drawing up the FAL and is meticulous in determining disorders and limitations. This insurance physician also believes that he takes time for and is involved with the client. A higher score for 'Behaviour: assessment' is therefore typical of an insurance physician who sticks to the guidelines, does not consider the specific situation of the client, thinks as he goes along, but still believes that he engages with the client.The variables 'FAL and recovery time: stringent/formalistic approach', 'Client approach: time for account of daily activities and reporting' and 'Client approach: too little time, but involved with' were omitted from the model.We modelled the direct effects between the endogenous variables as shown in Figure The correlations between the exogenous variables are shown in Table Some exogenous variables turned out to have relationships with the ASE concepts (see Table The disturbance term of the Attitude towards the profession and the system was positively associated with the disturbance terms of 1) being attached to the opinions of others in general , 2) having the experience of sufficient information and knowledge (Knowledge), and negatively associated with 3) that of the experience of barriers (Barriers)  was associated, although weakly, with less 'Behaviour: assessment'.The model showed a significantly better fit when the path from Self-efficacy to Behaviour: assessment was replaced by a direct path from Behaviour: assessment  to Self-efficacy . In plain terms, stringent and disorder-oriented physicians develop more Self-efficacy, which leads them to adopt more of the - expected - professional Intention and to perform more eager, in control and being prepared to compromise (Behaviour: process). This, in turn, has a (non-significant) negative effect on stringent, disorder-oriented assessments (Behaviour: assessment).The explained variances were for Intention 0.07, for Behaviour:: process 0.14 and for Behaviour: assessment 0.15  so it is perfectly feasible for the same - and other - aspects of Attitude to exert a positive effect on both.The positive connection between a positive attitude to the profession and system (Attitude) and being more influenced by others  seems to concur with the positive direct effect of being more influenced by others  on greater professional intention (Intention). This indicates that insurance physicians that perform more according to the norms of others have a stronger professional Intention and, at the same time, feel more positive about the profession and the social benefits system.Another notable finding is the direct negative effect of experience of more barriers (Barriers) on eagerness, taking control and willingness to compromise (Behaviour: process) as opposed to the direct positive effect of receiving knowledge and information more frequently (Knowledge) and sticking to the rules (Behaviour: assessment). It is conceivable that physicians who stick more to the rules have a greater need for knowledge and information . The latter profile goes hand in hand with a positive attitude to the profession and the social benefits system (Attitude). On the other hand, insurance physicians who experience more barriers (Barriers) - expressed as heavier work pressure and more frequent tiredness - may be less eager and feel more often that they have no control over the course of the assessment interview (Behaviour: process). The experience of more barriers also goes hand in hand with a less positive attitude to the profession and the social benefits system.In contrast to what was hypothetically expected of the ASE model, we found no direct effect for Attitude on Intention. This may be related to the fact that only three aspects were incorporated in Intention: promote recovery; importance attached to capability in the assessment; and importance attached to the account of the daily activities and home situation of the client. We also found no direct effect from Intention to Behaviour: assessment. This could mean that the questions to measure intentions (Intention) in the questionnaire were insufficiently attuned to behaviour during the assessment interview (Behaviour: assessment). In addition, the absence of direct effects between Attitude and Intention on the one hand and Intention and Behaviour: assessment on the other, may be caused by the narrow distribution of the variable Intention; the majority of insurance physicians scored high on the three additive scales that formed the latent variable Intention . FinallyThe results of the exogenous variables show that insurance physicians who have trained in a medical specialization (besides training as an insurance physician) differ from insurance physicians who have not. Training in another medical specialization turned out to be connected with being more influenced by others , higher Self-efficacy and a less stringent, guideline-based, disorder-oriented approach (Behaviour: assessment). These doctors listen to the opinions of other people but their confidence in their own professional ability makes adherence to the rules less important to them.Insurance physicians who, relatively speaking, carry out more assessments per week seem to pay less heed to the opinions of others. They also have confidence in their professional ability and a less strong professional intention whereby they do assume a stringent, guideline-based, disorder-oriented approach. Steenbeek et al.  showed tSteenbeek et al.  found thA large quota of clients from the industrial sector is connected with a more stringent, guideline-based, disorder-oriented approach whereas a large quota of clients from the retail sector is connected with a less stringent, guideline-based, disorder-oriented approach. These findings may have something to do with the culture of the organizations where the insurance physicians worked before the Employee Insurance Benefits Agency was founded in 2002. At that time the tasks were performed by Industrial Insurance Associations, which were autonomous organizations with their own sector and culture .Several studies have investigated the relationship between elements of the Theory of Reasoned Action and the Theory of Planned Behaviour  for Our measurements for Intention and Behaviour: assessment reflect to what extend insurance physicians follow the rules. Therefore, studies that show specific relevance to the present study are TPB-based studies on guideline adherence by health care professionals -68. ThesWe know of only two studies that investigated self-reported behaviour in a non-curative, occupational health setting on the basis of elements of the ASE model. In a study among occupational physicians Rebergen  found noArmitage and Conner  found inOne of the strengths of this study is that the response to the survey was considerably higher than for most other surveys among insurance physicians. Another is that we managed to measure the latent ASE constructs, which were interpretable, and in relating them in a good fitting path model.One of the weaknesses is the cross-sectional research design, which does not allow for the analysis of causal relationships. Another is that we may not have sufficiently synchronized the questions for the various ASE constructs. For example, the theory on intention and behaviour says that intention is an important predictor of behaviour. We probably did not sufficiently define Intention for our goal: explain the assessment behaviour of insurance physicians (Behaviour: assessment). If we had, Intention might have played a more pronounced role in the model. On the other hand, we did find a relationship between Intention and behaviour related to the assessment process (Behaviour: process). A final weakness relates to the fact that our final model was established on the basis of certain specification choices. It is theoretically possible that other choices would result in another fitted model. We did, however, explore some of the alternative models to arrive at our final model. However, since a lot of modification went on in the model-building process, the findings would need to be replicated, most preferably by confirmatory path analysis in an independent sample. Especially, it is necessary to replicate the scales and dimensions, which we used in the measurement models in this study for the ASE-constructs. Perhaps, items could be developed that distinguish between specific goals and their saliency of intention of social insurance physicians, In addition, items should be developed that describe behaviour more specifically in terms of the Target, Action, Context and Time (TACT) principle .In 2004 the Dutch Council for Health Care Research (CHR), a government body, stressed the need to research the variation in disability assessments performed by insurance physicians in the Netherlands . RelevanIn conclusion: we found associations in a path model of Attitude and Intention with self-reported Behaviour related to the process and content of occupational disability assessments by insurance physicians. However, the results from this study do not fully confirm the relevance of the Attitude - Social norm - Self-efficacy model in this setting because important associations of the ASE model were not supported. Further research is needed to determine whether the ASE variables measured at the level of insurance physicians are actually associated with the outcome of the occupational disability assessments of clients. If so, we can investigate if assessment behaviour can be influenced in order to limit systematic inter-doctor variation in the outcome of disability assessments.The authors declare that they have no competing interests.AJMS and RS performed the statistical analysis and wrote the manuscript. HM, JRA, HK and JB revised and commented on the manuscript. RS, HM, HK and JB coordinated the data collection. HK provided the logistics for the questionnaire. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/576/prepubScales and dimensions. Meaning of all measurements .Click here for fileThe development of the model. Research model, adjusted model and final path model.Click here for file


A preliminary study was conducted on the development of an intelligent dental handpiece with functionality to detect subtle changes in mechanical properties of tooth tissue during milling. Such equipment would be able to adopt changes in cutting parameters and make real-time measurements to avoid tooth tissue damage caused by overexertion and overextension of the cutting tool. A modified dental handpiece, instrumented with strain gauges, microphone, displacement sensor, and air pressure sensor, was mounted to a linear movement table and used to mill three to four cavities in >50 bovine teeth. Extracted sound frequency and density were analyzed along with force, air pressure, and displacement for correlations and trends. Experimental results showed a high correlation (coefficient close to 0.7) between the feed force, the rotational frequency, and the averaged gray scale. These results could form the basis of a feedback control system to improve the safety of dental cutting procedures. This article is written in memory of Dr Hongyan Sun, who passed away in 2011 at a young age of 37. The dental handpiece is thus the most fundamental instrument used by the dentists. However, it is also the instrument most likely to cause tissue damage. The most common type of dental handpiece is an air turbine rotating at very high speeds, which range from 160,000 to 800,000 r/min. It is usually used “blind,” with no feedback, other than what the dentist can feel through the grip. Breaching into the pulpal space or sinus may occur due to overextension of the cutting tool, leading to permanent damage to tissues. Therefore, from a patient’s perspective, the development of an “intelligent” dental handpiece, which can identify the subtle changes in the cutting conditions and stop the cutting process automatically before overextension of the handpiece can occur, would be advantageous. In order to achieve this aim, it is essential to first study the operational parameters such as the cutting force and rotational frequency of the handpiece and then to analyze the relationships between the tissue properties. In practice, the air pressure supplied, the rotational frequency of the handpiece, and the cutting force applied are all highly variable and operator sensitive. Therefore, as a preliminary investigation, the dental milling procedure was studied using a laboratory setup whereby the feed rate could be controlled and where some of the operational parameters could be studied systematically.Drilling and milling with dental handpieces are common procedures in restorative dentistry. Handpieces are used in the removal of carious  tissues, cavity preparation for the placement of restorative materials, tooth reduction for the construction of prostheses, 2 The measure of these parameters through laboratory-based investigations have been used primarily for comparative testing and handpiece selection,3 evaluation of their effect and that of the bur type on tooth damage,4 fault diagnosis of equipment,5 and the improvement of drilling performance through the design of suitable drill bit materials,6 and so on. However, there have been few studies considering the relationships between the operational parameters of a dental handpiece and properties of the tissues being cut. Such studies can be found in other research areas. For example, in their study of bone, Ong and Bouazza-Marouf8 find that the bone drilling forces have the potential to provide useful information about the strength of bone. The effects of system compliance and inherent drilling force fluctuation on the profiles of drilling force are explored, as well as the force variations in the drilling force between successive samples and the drill bit’s rotational frequency. It is shown that these effects have significant influences on the bone drilling force profiles and thus on the detection of drill bit breakthrough. In a series of studies, Brett and colleagues911 introduced an autonomous surgical robot for ear surgery. The robotic system monitors the force and torque transients at the drilling tool point and interprets these in real time. The relationship between the transients can be used to distinguish between the different states and phenomena, such as patient or tool movement, the approach to tissue boundaries, changes in tissue hardness and stiffness, and drill breakthrough. Using part of this information, it is possible to predict the critical breakthrough event before it occurs and automatically control the drill penetration with minimum protrusion.Previous studies have provided many methods for monitoring the operational parameters in vitro.More than 50 bovine teeth were used in this experiment. Using an orthodontic resin, each tooth was vertically mounted in the middle of a Teflon ring, as shown in As shown in The experimental procedure was described as follows.The Teflon ring with the tooth sample was secured onto the movement table.The position and angle of the modified handpiece were adjusted so that the bur lay perpendicular to the linear movement table and positioned touching the tooth’s side surface.The displacement sensor was zeroed, and the data collection software was activated to begin recording the sound, feed force, displacement, and air pressure.The air and cooling water supplies to the handpiece were turned on, and the control program for the movement table was activated to drive the tooth sample toward the bur at a rate of 0.03 mm/s.2.During cutting, the air pressure was maintained manually at an approximate value of 29 lbf/inThree to four slots, measuring less than 1 mm deep, were milled over the top surface of the flattened tooth sample.Finally, the sample was placed in a micro-computed tomography (CT) machine (Metris XT H 225) to measure the gray scale values within each milled slot.Sound pressure was collected at a sampling frequency of 22,050 Hz. The sampling frequency was chosen to be greater than twice the maximum rotational frequency (7000 Hz), in accordance with signal processing theory for the avoidance of aliasing. The fast Fourier transform was performed for every 16,384 sound samples to extract the frequency spectrum. The main frequency within 1000–8000 Hz in the frequency spectrum was taken as the rotational frequency of the handpiece.A tooth sample with three parallel slots made on its surface is shown in Over the course of the study, over 150 slots were milled in more than 50 bovine teeth. All the millings showed similar results. For illustrative purposes, the results of one, randomly selected, slot will be shown. The relationships between some of the operational parameters and the tissue gray scale are shown in the following sections.In this study that simulated the tooth reduction process via milling, some of the dental handpiece operational parameters were evaluated and their changes with the tooth anatomy examined. The monitoring of the operational parameters during the simulation indicated that changes in parameters such as rotational frequency and feed force could be used to identify changes in tooth anatomy.The gray scale values obtained from a micro-CT scan reflect the ability of materials to absorb X-rays. It is therefore possible to use the gray scale values to distinguish between different tooth tissues. For materials with the same chemical compositions, their gray scale values will depend mostly on their densities. The denser a material is, the higher the gray scale value and vice versa. This can be seen in the results shown in The feed force can be used to detect changes in the mechanical properties of the tooth tissues during milling of the tooth. It is expected that a softer, more compliant material would yield a lower feed force, while a harder, more brittle material would result in a larger feed force. The handpiece’s force response in 13 stroboscopes,1416 optical counting devices,1720 magnetic systems,2124 and sound frequency detectors.25 Of these methods, sound frequency has been one of the easiest techniques to implement. Ball and Davidson25 have used both a close-proximity variable inductance vibration pick-up system and a separate microphone to measure air-turbine speeds during clinical use. Additional research by Morrant26 has found that the predominant sound frequency is equivalent to the rotational speed. Using sound frequency as an indicator of rotational speed, this study has measured the handpiece’s bur speed. The dental handpiece operates at a very high narrow frequency band which background noise cannot reach under normal conditions. Band filters can be used to remove background noises and harmonics. More than 150 cavities were milled, yielding results similar to The third parameter explored in this study was rotational frequency. Rotational frequency of dental handpieces has been measured using methods such as mechanical tachometers,It is recognized that this study used a rather idealized simulation to represent the actual clinical situation. For example, the bur was clamped and remained perpendicular to the occlusal surface during the movement. A constant and very slow displacement rate (0.03 mm/s) was also used. And only the cutting of healthy dental tissues was considered. In reality, the bur is not always perpendicular to the tooth surface. The rate of displacement is also faster and more varied. Furthermore, the bur is used to remove restorative materials, for example, in replacing old restorations as well as tooth tissues.2629 The large fluctuations in the feed force/rotational frequency produced when hard and brittle tissues were being cut made it difficult to detect, for example, the transition of the bur from enamel to dentin. It is conceivable that the magnitude of the parameters and their fluctuations could also vary with the cutting speed and air pressure, thus confounding the problem. In addition, the bur has a finite diameter of about 1 mm, which is comparable to the enamel thickness. This will also smear the transition, as it will take a finite distance for the bur to completely move from one region into the other. The gradual increase in the feed force as the bur first milled into surface enamel was probably the result of this gradual increase in the contact area between the tool and tissue. Furthermore, decayed dentin may be mistaken as the pulp because of its softness.Tooth structures are very complicated, with tissue properties being highly variable with anatomical position.Another factor that may give rise to complications has to do with the fact that each handpiece will have its own compliance and cutting characteristics dependent on its internal mechanics. This would require a new calibration for each device. While the overall trends and responses between operational parameters should be similar, clinical conditions will further complicate the design of a control system for the device. The exact response of the handpiece will probably depend on the firmness of the dentist’s grip, the angle of cutting, the speed of motion, and the applied air pressure, which is often intermittent.It seems hard to only use force and rotational frequency to identify real-time cutting tissues. It may therefore be necessary to combine multiple parameters and to perform more detailed signal processing in order to better identify the transitions from one region to the other. It may also be necessary to augment the mechanical data with positional data, supplied in real time by sensors attached to the handpiece and the patient, to help determine, for example, the position of the bur relative to the pulp, whereby early warnings to possible breaching can be provided.This study recognizes the clinical constraints of the design of a high-feedback device. The first step has been to identify possible trends between the operational parameters. Additional research, such as looking beyond the main sound frequency and into transients and global positioning may provide important information. Despite this study’s limitations, there was a very distinct change in the feed force/rotational frequency profiles, which also became much smoother, when the softer dentin close to the pulp was being milled. This strongly suggests that an instrumented handpiece may be able to detect the approaching pulpal space before breaching occurs. Furthermore, this tool may serve as a means to safely and more precisely remove restorative materials without destroying healthy tooth tissues in the process of replacing old restorations.In this preliminary investigation, conclusions can be made that the feed force and rotational frequency of a dental handpiece operated with a constant air pressure and milling rate are directly correlated. Furthermore, the two parameters have a close relationship with the mechanical properties of the tissues being removed. It thus appears possible to detect changes in tissue properties during cavity preparation through the changes in these operational parameters.