Previous research has shown that reducing physical workload among workers in the construction industry is complicated. In order to address this issue, we developed a process evaluation in a formative mixed-methods design, drawing on existing knowledge of the potential barriers for implementation.We present the design of a mixed-methods process evaluation of the organizational, social, and subjective practices that play roles in the intervention study, integrating technical measurements to detect excessive physical exertion measured with electromyography and accelerometers, video documentation of working tasks, and a 3-phased workshop program.recruitment, reach, fidelity, satisfaction, intervention delivery, intervention received, and context of the intervention companies. Observational studies, interviews, and questionnaires among 80 construction workers organized in 20 work gangs, as well as health and safety staff, contribute to the creation of knowledge about these phenomena.The evaluation is designed in an adapted process evaluation framework, addressing At the time of publication, the process of participant recruitment is underway.Intervention studies are challenging to conduct and evaluate in the construction industry, often because of narrow time frames and ever-changing contexts. The mixed-methods design presents opportunities for obtaining detailed knowledge of the practices intra-acting with the intervention, while offering the opportunity to customize parts of the intervention. Musculoskeletal disorders are a major economic, social, and health challenge in the construction industry, as well as in other occupations characterized by high levels of physical exertion at work ,2. PhysiAs a consequence of this limited success in preventing musculoskeletal disorders in the working population in general, and for construction workers in particular, evaluators and researchers have called for more multidisciplinary-anchored interventions ,6,8. FurIn response to this, we have tailored an intervention that engages workers and management, and integrates the use of technical quantitative measurements of excessive physical workload measured with electromyography and accelerometers, video documentation of working tasks, and a 3-phased workshop program. Whereas Brandt et al  describeResearch shows that reducing physical exertion in construction work is a complex issue ,17. As NConstruction work is a broad category that encompasses many different trades composed of different tasks, skillsets, and cultural norms. However, physically exerting work is a common denominator. Across carpentry, bricklaying, concrete work, scaffolding, plumbing, etc, the entangled body and subjectivity of the worker is a main resource of production, a point that takes a line of arguments to unfold. However, it is highly important for understanding the social framing of the intervention context.The necessity of undertaking tasks in a physically exerting manner is embedded in the organization of work, where planned availability and usage of technical assistive devices play important roles. Technical assistive devices have the potential to substantially decrease physical exertion at work, but numerous political, organizational, and subjective agencies challenge the development, proliferation, and usage of such technical assistive devices -21. ThusOne of these agencies lies in the material and organizational orchestration of work that takes place at geographically delimited sites for a certain amount of time, after which, on project completion, the whole organization breaks up to be reconfigured at new worksites. Here the tasks involve many of the same skills but are usually still markedly different, and pose new and different flows of processes, still containing physically exerting work tasks. For this reason, planning of construction sites is a complicated matter, in which the usage of technical assistive devices is sometimes not thoroughly considered. This means that adequate measures for reducing physical exertion may not always be present in the construction process. Without a rigorous process evaluation, important opportunities and barriers in this regard could easily be missed.At a political and societal level, the competition among entrepreneurs to secure projects has been described as a barrier for implementing initiatives prioritizing health and safety ,22. In pFurthermore, many construction projects are completed on some form of performance-based payment , which provides the worker with an economic incentive for working faster with less variation, and not using technical assistive devices unless they directly increase production -24. ThisIn previous studies, communication between the managerial staff and workers has been suggested as a potential barrier to improving health and safety at the workplace ,25. EvenIn addition, many construction workers embody and socially transmit traditional masculine working-class qualities ,29, suchIn our evaluation, all these agencies and their entangled roles are points of attention, as we aim to understand the facilitators and barriers to reducing physical exertion. The purpose of the process evaluation is to investigate how the intervention intra-acts with both the worker’s body and subjectivity, as well as social and organizational relations acting as facilitators and barriers to reducing physical exertion. An additional aim is to perform analyses using the mixed-methods design to evaluate potential consequences of the intervention in terms of productivity, sickness absence, and time frames.The intervention is taking place in a design containing several phases as thoroughly described by Brandt et al .In the first phase of the intervention, 20 construction gangs (N=80 workers) will be randomly assigned at a cluster level to a participatory intervention group or a control group. We will record in situ physical workload during a working day using technical measurements  before and after the intervention. Based on these measurements, a physical load matrix for each worker will be developed. This matrix is based on outcomes obtained from the analyses of the simultaneously recorded electromyograms and accelerometer data.The second phase is designed as a participatory process consisting of 3 workshops: 1) workshop I at baseline, involving presentation of video clips of the work tasks with excessive physical load customized for each gang, followed by a participatory development of solutions on how to reduce excessive workloads, leading to the development of an action plan on how to implement these solutions at the workplace, 2) workshop II, where the implemented solutions will be further developed and qualitatively evaluated during group discussion, 3) workshop III at follow-up to enhance long-term organizational sustainability of the implemented solutions. All workshops will aim to include researchers, workers, occupational health and safety (OHS) staff at the companies, and a management representative as participants. We will facilitate the elaboration of solutions aimed at lowering the physical exertion related to the participants’ suggestions. The control groups are not targeted in the evaluation study and are therefore not addressed in this protocol.recruitment, reach, fidelity, satisfaction, intervention delivery, intervention received, and context [The evaluation is designed in a mixed-methods framework to address different aspects of the intervention, which has been recommended by several sources on evaluation research ,31. To a context . BecauseRecruitmentNumber of companies asked to participateNumber of companies agreeing to participateNumber of gangs participating (intervention and control groups)Number of workers participating (intervention and control groups)Number of workers responding to questionnairesNumber of workers asked to participate in interviewsNumber of workers participating in interviewsNumber of occupational health and safety (OHS) staff asked to participate in interviewsNumber of OHS staff participating in interviewsReachNumber of technical measurements completedNumber of workshops completedFidelityThe extent to which the workshop program was completed in accordance with intentionsSatisfactionWorkers’ and OHS staff’s satisfaction with prioritized risk factors, the competencies of workshop facilitators, and the time for workshopsWorkers’ and OHS staff’s satisfaction with the method of the workshopsWorkers’ and OHS staff’s satisfaction with the implementation of measures for improving ergonomic work environmentIntervention deliveryPerceived intervention implementation according to researchersIntervention receptionPerceived intervention implementation according to workers and OHS staffIn our evaluation, recruitment is defined by several parameters: 1) the number of companies asked to participate, and 2) the number of companies agreeing to participate. We will also record 3) the number of work gangs randomly assigned to the intervention and control groups, as well as how many of these completed the study, 4) the number of workers and OHS staff asked to participate in the intervention at each participating company, to answer questionnaires and to participate in interviews, and 5) the number of workers and OHS staff agreeing to participate in the study, to answer questionnaires and to participate in interviews.Reach can be defined as the proportion of the intended recruited participants who actually received the intervention, as defined by Saunders et al . In our After each workshop, we will ask all participants to complete a questionnaire addressing workers’ and OHS staff’s perceptions of the workshop. Fidelity will be addressed in 2 ways. First, we will ask workers to rate each workshop phase on a 5-point scale . Second, we will record all activities of the workshops to assess whether they were completed in accordance with the planned activities.Likewise, we will assess satisfaction based on the workers’ and OHS staff’s satisfaction with 1) prioritized risk factors, 2) the competencies of workshop facilitators, 3) the time frames for the workshops, 4) the structure of the workshops, and 5) the implementation of solutions for lowering physical exertion and improving the work environment. All of these parameters will be rated on 5-point scales . Through qualitative interviews in selected cases, we will gain further knowledge of workers’ and OHS staff’s satisfaction with and knowledge of particularly well-functioning or dysfunctional elements of the intervention. This will allow us to use the evaluation in a formative manner, adjusting the intervention for better implementation, as previously suggested ,36.intervention, delivery, and reception is based on the definition by Saunders et al [dose delivered. Referring to a complex organizational and ergonomic intervention as a dose does, however, in our opinion, risk confusing the intervention with a medical injection, which would be misleading because the intervention is a framework for developing preventive solutions that intra-acts with other agencies in work and organizations. The intervention should not be seen as something we inject into the organization with determinate effects.What we term rs et al , originaImmediately after completing each day of technical measurements and each workshop, the facilitating researchers will have an evaluative meeting. Minutes of the meeting will be produced to evaluate the success of the activities. Furthermore, we will conduct observational studies at the worksites during 2–5 workdays between workshops I and III in order to assess whether solutions on how to reduce excessive workloads were actually used during work. We also record the number of visits and observations during these visits.After each workshop, we will evaluate the intervention received by using questionnaires. We will ask each of the workers and OHS staff to assess whether the decided measures have been implemented and integrated as part of work. This will be answered on a 5-point scale . More precise descriptions of the measures that were actually implemented will be explored through interviews with participants.We will investigate the intervention context through interviews with workers and OHS staff to explore their positioning in relation to different agencies intra-acting with the intervention. To address the subjective, social, and organizational practices intra-acting with the implementation of the project, we have designed an in-depth qualitative study consisting of observations, interviews, and document analysis. The qualitative design focused on a limited number of intervention cases offering insights on productivity, sickness absence, and time frames, as well as how the intervention intra-acts with worker identity and meaning in work as initially described.critical case argumentation for validity and generalization from case study research. Our aim is to select 2 cases (gangs) in which the implementation seems to be particularly successful, and 2 cases in which the intervention seems to meet resistance or other barriers. By selecting “best” and “worst” cases, we have the opportunity of making generalizations of the type “if the implementation meets X as a barrier/facilitator in this case, it will be likely/unlikely to work better/worse in other cases’ [For the qualitative study we will select 4 work gangs based on a r cases’ .We will distribute the survey questionnaires to the workers of both the intervention and control groups at the time of the initial technical measurements and again after the intervention period. The questionnaire will contain questions addressing the physical work environment and several risk factors of particular relevance to work in the construction industry drawn from previous research ,22,38. OThese questionnaires will be handed out to participants of the intervention group directly after each workshop and will address fidelity, satisfaction, and the intervention delivered.context above, we will select cases for interviews through a critical case definition, as discussed by Flyvbjerg [We will conduct interviews with the intervention group and address the workers’ and OHS staff’s satisfaction and context. As described for lyvbjerg . Based olyvbjerg ). The inWe will conduct the interviews between workshops II and III to ensure that the participants have the intervention fresh in their memories, while also having some experience of the action taking place during the intervention.All interviews will be transcribed and imported to NVivo  for coding and to facilitate the analysis. The interview analysis will draw on a view of lingual productions as positioning in discursive-material practice in an analytical framework composed on the thoughts of Davies and Harré  and BaraObservations will be conducted in 2 forms and particularly address the delivery of the intervention as well as the context. First, we will video record all workshops in the project to permit analysis of the processes taking place during the workshops. This analysis will illustrate the communication concerning lowering physical exertion through the intervention. In particular, we are interested in how participants use the technology and what solutions are reachable in the interplay between workers, health and safety professionals, and management. We will also analyze this observational material through positioning theory  in a modSecond, a researcher will follow the work at the intervention sites during the intervention period in order to gain insight into the practices in the organization during the time of implementation. These observations will be drawing on observational methodology and analysis by Czarniawska, who suggests observing particular practices, objects, or people . From thIn the participating companies, we will obtain documentation of sickness absence, time frames, and economic measurements . Through analysis of these documents, we will attempt to gain insight into some of the measures of how the intervention affects productivity, which is very important to estimating the potential costs of this type of intervention.We will analyze the different empirical elements of the study in relation to each other. We will focus on combining triangulation and a complementary approach to the mixed-methods design rather than on quantifying qualitative material or other approaches to mixed methods . In pracAt the time of submitting this paper (February 2016), we have made initial contact with cases for the intervention and evaluation, and 40 workers have agreed to participate so far. We have completed evaluation design and have prepared interview guides and the observational methodology. The intervention and evaluation are designed to run over the course of winter 2015 to winter 2016, after which time we will undertake the analysis.One practical issue when conducting research, interventions in particular, in the construction industry can be that time frames are often very narrow, which is why workers often do not have the time to participate in interventions. One particular challenge will be to engage workers, OHS staff, and managers to cooperate in developing and implementing solutions for reducing physical exertion in work, as these groups are usually not engaged in such activities. These challenges can complicate our aim to complete the workshops and group interviews. We will, however, attempt to follow through.A particular strength of the evaluation design is the mixed-methods framework. Through using lingual communications, observed practices, and quantified assessments, we have configured an analytical apparatus capable of describing how the intervention intra-acts with the workplaces in which it is implemented. We get the opportunity to identify mutually supportive configurations of these relationships, as well as the ability to identify differences occurring through only one or two methodological approaches.Also, the formative evaluation design allows us to use the insights produced through the evaluation to customize parts of the intervention to better address the context’s or participants’ requirements for a fruitful implementation.However, we do expect that completing the mixed-methods analysis of the various sources of data and measurements will pose significant challenges. For instance, weighing the different approaches in relation to each other will demand attention and carefulness in the research group working with the study. For these reasons, we expect to be able to illustrate how agencies in construction work intra-act in relation with the ergonomic intervention and to reconfigure the boundaries of material work, organization of physically exerting work tasks, and worker subjectivity. These insights will provide pointers for future action and interventions targeting physical exposure in construction work.


Unequal distribution of specialist doctors in Indonesia has been identified many years ago. Government has taken several measures to address this issue. However the phenomenon is still present today. In the year 2014, Indonesia will apply universal health coverage which needs specialist doctors to support it. The failure to provide specialist doctors would increase inequity, particularly for those who live in islands, border, and remote areas. On the other hand, specialist doctors who are appointed by public hospitals as full-time doctors, do a dual practice. They spend more time in other institutions rather than in public hospitals. This study aimed to examine the association among demographic factors, number of hospitals, type of hospitals with distribution of specialist doctors, and to measure the level of engagement of specialist doctors in the public hospitals as their main designation.A mixed method was used, emphasising on quantitative approach, which supported by qualitative approach to explain the previous findings. Secondary data measuring the distribution of specialist doctors and related variables were collected from the MoH and National Bureau of Statistic. Primary data were collected from 3 public hospitals in 3 different areas, representing 3 different characteristics of distributions. Statistical and qualitative analyses were employed to examine the data. The Ethical Committee of Faculty of Medicine UGM enacted ethical clearance for this research.Distribution of specialist doctors were positively associated with population, number of private hospitals and negatively associated with fiscal capacity and number of public hospitals. Distribution pattern in Indonesia has been identified as static distribution and dynamic distribution. In the static distribution areas, the existence of specialist doctors could not be found. Engagement of specialist doctors in the public hospitals was associated with professional facilities, medical fees, and flexible hours provided by the hospital managers. Barrier to entry was found as a negative factor to increase engagement level.Distribution of specialist doctors in Indonesia ranged from static distribution areas to dynamic distribution area. Within the dynamic distribution areas, engagement level of specialist doctors in the hospitals was low. It implied to the pattern of specialist doctor distribution in general. Both factors, type of distribution and engagement level, created a circle to affect distribution of specialist doctors in Indonesia. Policy makers should develop special policy to improve distribution of specialist doctors in particular area and to endorse new concept of “sustainability of services provided by simultaneous team”.


Ebola virus disease is a viral hemorrhagic fever, first discovered in 1976 in Sudan, where the outbreak infected over 284 people with a 53% case fatality ratio. There have been 34 further epidemics, the current major incident in West Africa having recorded more cases and deaths than all previous outbreaks combined. To date there have been over 27, 000 confirmed, probable and suspected cases and 11,000 reported deaths in Liberia, Guinea and Sierra Leone. With total funding and pledges to help control the outbreak amounting to more than US$2.4billion, many question how the disease has continued to spread in Sierra Leone and Guinea Conakry, and whether the response to the outbreak has been justified. This article aims to analyze the effectiveness of the responses to the outbreak in terms of economic, social, cultural and, to an extent, political impact. We argue that the response has been justified due to the awareness raised, the infrastructure and staffing improvements, the success in receiving financial aid and the minimal spread to other countries outside the main transmission zone. Despite this, some failures in communication and a slow early response were noted. The Ebola Virus Disease (EVD) outbreak emerged in a remote corner of Guinea in December 2013, and spread into Liberia and Sierra Leone in the context of weak health systems in all three countries .In most of the affected areas interventions like case contact tracing and follow-up, referrals to a health centre when a case is suspected, safe burial practices and disease surveillance at community level were not routinely carried out. There was an insufficient number of case management centres despite the daily increasing demand. The already fragile National Health System in Guinea was rapidly overwhelmed leading to the inevitable accelerated spread of Ebola , 2, 5.The situation required the implementation of immediate and vigorous additional interventions to stop the spread of the epidemic. International aid and support increased and many organizations and institutions joined the response with several projects implemented on the ground. Despite this, the disease continued to spread rapidly in the country. Moreover reports from the media and staff on the ground stressed community resistance and fear. There were individuals with symptoms refusing to seek care in the formal health system and instead resorting to home treatments from local pharmacies or traditional healers. With fear, despair and death all around, the community reluctance moved to an extreme level with riots and killings which started in April 2014, less than one month after the official confirmation of the epidemic. By September, eight people, including journalists, Ebola-related educators and health technicians had been killed in Guinea .Many experts have attempted to explain the reasons behind the community resistance but most analysis was based on comments, testimonies and observations , 5. CommIt is widely acknowledged that understanding and addressing communities’ needs and working side by side with local populations can significantly impact disease burden in affected communities. To support the efforts of the government and other institutions and organisations engaged in the fight against the expanding Ebola virus epidemic in Guinea, and to define appropriate strategic measures as part of a long term programme of health system strengthening, Amref Health Africa initiated a rapid assessment in selected sites at the peripheral level of the health system in their supported communities to identify gaps in Ebola response actions and understand the root causes for failure. This paper reports the main challenges faced by frontline health services and communities, and explores the perceptions and views on the current Ebola response in the Prefectures of Coyah and Forecariah in Guinea.To describe and explain the various interventions to the outbreak and the collective and respective impact of each on the epidemiological, clinical, economic, social, cultural and, to an extent, political dynamics, we conducted an analytical review of all scientific and media publications related to the EVD epidemic.Having been in a period of peace and economic recovery, Liberia, the Republic of Guinea (Guinea-Conakry) and Sierra Leone have since the onset of the EVD outbreak experienced reversal of development gains. The actual growth for 2014 for the three countries fell short of the projected growth figures from before the EVD epidemic  and thisIn addition, the total fiscal impact of EVD is more than US$500million in 2014 alone, imposing additional budgetary needs of more than 6.0 percent of GDP in Liberia, more than 3.0 percent in Guinea, and more than 2.5 percent in Sierra Leone .Guinea, Liberia and Sierra Leone all have very weak health systems with lack of adequate infrastructure and qualified personnel . Table 2Having never encountered EVD before, many people in West Africa did not understand why they had to adapt their routine daily practice, while not enough people sought medical care in hospitals. There was an outburst of false rumors and violent attacks  as a resPublic awareness, border screening, healthcare worker training and setting up isolation facilities are all crucial in the identification and early diagnosis of imported EVD cases . EVD hasWithout the current intervention, the CDC estimated that the number of EVD cases in Liberia and Sierra Leone alone could rise to between 550,000 and 1.4 million in 2015 . There hHigh CFRs and a great deal of suffering are caused by EVD. The average EVD CFR is around 50% but up to a 90% CFR has been recorded when no treatment is provided . HydratiIt can be concluded that the overall response has been justified despite some failures. Donations have helped relieve some of the financial pressure in West Africa, improvements to the infrastructure and staffing are being made, awareness has been raised and little spread to the rest of the world has been noted. The drugs and vaccines developed could also be justified, but that is not clear yet. Although there has been a great amount of fear caused, which in turn has consequences, and not all methods used have been effective or appropriate, there are lessons to be learnt with reasons to improve response for future disease outbreaks. Importantly, as far as Ebola treatment is concerned, the medical community has learned what is effective in the simple therapeutic compendium, such as aggressive rehydration of patients.


Background. The early detection of rheumatic diseases and the treatment to target have become of utmost importance to control the disease and improve its prognosis. However, establishing a diagnosis in early stages is challenging as many diseases initially present with similar symptoms and signs. Expert systems are computer programs designed to support the human decision making and have been developed in almost every field of medicine. Methods. This review focuses on the developments in the field of rheumatology to give a comprehensive insight. Medline, Embase, and Cochrane Library were searched. Results. Reports of 25 expert systems with different design and field of application were found. The performance of 19 of the identified expert systems was evaluated. The proportion of correctly diagnosed cases was between 43.1 and 99.9%. Sensitivity and specificity ranged from 62 to 100 and 88 to 98%, respectively. Conclusions. Promising diagnostic expert systems with moderate to excellent performance were identified. The validation process was in general underappreciated. None of the systems, however, seemed to have succeeded in daily practice. This review identifies optimal characteristics to increase the survival rate of expert systems and may serve as valuable information for future developments in the field. Rheumatologic diseases manifest themselves in varying combinations of symptoms and signs, particularly at early stages, and therefore make differential diagnosis a challenge, especially for nonrheumatologists including general practitioners. Since diagnosis at an early stage and adequate treatment improve prognosis, assistance in establishing diagnosis is desirable. Given the substantial progress in computer science in the last years, the idea of computers taking the role of diagnostic support is not far-fetched. Software applications have affected decision processes in clinical routine, for example, in controlling depth of anesthesia  or in de⋯ THEN⋯ rules [Pandey and Mishra distinguished between knowledge-based systems and intelligent computing systems . There aN⋯ rules . The rulN⋯ rules . In caseN⋯ rules . The typThe approaches to intelligent computing systems are artificial neuron nets, genetic algorithm, and fuzzy systems. Artificial neuron nets are built like biologic intelligent nervous systems and are regarded as learn-like . IndividBayes' theorem is a statistical method. The probability of a diagnosis is calculated with the accuracy of a test or a clinical finding and the prevalence of the disease . Thus BaDifferent methodologies are often combined, which are then called hybrid expert systems .Already in 1959, Ledley and Lusted anticipated the use of computers in supporting decisions and proposed different mathematical models to emulate the reasoning in medical diagnosis . Since tSeveral somewhat outdated review articles explored the development and application of expert systems in medicine in general , 10, 14.Besides an overview of characteristics, comprehensiveness, and validation of existing diagnostic expert systems in rheumatology, this systematic review seeks to point out whether the current expert systems fulfill the expectations of clinicians in daily practice and finally what the characteristics of an optimal system would be.The systematic literature review was carried out following the PRISMA statement . No ethiIn the optimal scenario we anticipated to find comprehensive reports on each individual diagnostic expert system including information on the precise diagnostic algorithm, the targeted diseases, a well-described validation cohort, and predictive values for diagnostic performance. The data would allow for a statistical comparison of the expert systems. In a suboptimal scenario, only descriptive reports of expert systems will be found allowing for a comprehensive overview of the past developments without statistical comparability.Medline, Embase, and Cochrane Library were searched using the following Medical Subject Heading (MESH) terms: “rheumatic diseases,” “rheumatology,” “arthritis,” “computer assisted diagnosis,” and “expert systems.” No restrictions were placed on publication date. Only literature in English or German was considered. The last search was run on February 10, 2014.The literature was screened based on title and abstract of the records. All publications referring to diagnostic expert systems in rheumatology or in a rheumatic subfield were included. Reviews, editorials, and literature which described an expert system only used for education of healthcare providers and therefore not used in diagnostics were excluded. Also, literature that referred to an expert system used for identifying solely the stage of a disease and hence not used for diagnosing a disease itself was excluded. Records which described an expert system applied only to image analysis were not considered either. Literature referring to data mining strategies using index diagnoses or solely epidemiological variables was excluded as well. Year of the last update of the system, number of considered rheumatic diseases, targeted diseases, information to feed the expert systems , methodology of the inference mechanism, and embedding of accepted disease criteria sets such as the American College of Rheumatology (ACR) or The European League Against Rheumatism (EULAR) criteria were extracted using standard forms.For the description of the validation method and the performance, the following information was extracted from the articles: number of cases used for the validation, determination of the resulting diagnosis, identification of the correct diagnosis, the reference diagnosis, percentage of correctly identified cases, sensitivity and specificity, positive predictive values, negative predictive values, positive likelihood ratio, and negative likelihood ratio.Only descriptive statistics are reported. Statistical analyses could not be performed due to the lack of information.A total of 10,282 references were identified using the search strategy. Seventy-three articles related to diagnostic expert systems in rheumatology were included. Nine duplicates were excluded. The remaining 64 full text articles were then assessed. One record describing an expert system developed solely for education  and one The reference standards were chosen differently: diagnoses according to established criteria, consensus diagnoses, discharge diagnoses, and diagnoses provided by a rheumatologist were used most often as reference. Three expert systems presented certain criteria for the determination of the resulting diagnosis when several diagnoses were presented as a result or when a probability value was added to the diagnosis. An article that reports on the applicability of a rheumatological expert system in clinical routine could not be identified in the published literature.The main result of this systematic review is threefold. First, an overview over 25 different diagnostic expert systems designed for rheumatology is given. Second, it is shown that the different designs and validation methods of the expert systems hinder the comparison of their performances. Third, we found no publications reporting on the routine application of an expert system in rheumatology.Artificial intelligence has achieved enormous progress in its development and computers have outclassed human beings in various fields, such as computer chess or IBM's Watson winning on the quiz show “Jeopardy!” Given this progress in technology and the time period covered by this systematic review of over forty years, the low number of identified expert system is surprising. The reasons would be either low interest in supportive software or, more likely, the difficulties encountered in simulating the complex human diagnostic process. Spreckelsen et al.  reportedNevertheless, the growing understanding of diseases and the corresponding findings or symptoms will facilitate the representation of medical knowledge and decision processes in the future.In consequence of the variation in the method of validation, the achieved validation results could not be compared with each other. The reason for this variability probably lies in two elements.First, the result of the expert systems to be compared with the reference diagnosis was presented in different ways. Some expert systems indicated a probability value of the calculated resulting diagnosis, and others present a hypotheses list. Final diagnoses in rheumatology often remain descriptive or incomplete and evolve over time as many of the rheumatic disorders present atypically and do not completely fulfill a diagnostic criteria set at the beginning. This issue is met by the presentation of the results as a hypotheses list or probability values, which can, as an important advantage, multiply the user's own differential diagnosis and lead to more focused testing. Yet, this method causes difficulties in the validation and the comparison of expert systems. For example, the diagnostic accuracy is erroneously high if a diagnosis at a low position in the hypotheses list or a diagnosis with a low probability value is accepted as a correct resulting diagnosis during the validation process.Second, there is a lack of widely accepted reference standards for the correct diagnosis to compare the resulting diagnosis with. Some authors used diagnoses in medical records or discharge diagnoses as a comparator assuming the correctness of their peers, some chose the consensus of rheumatologists, and others used diagnoses according to official diagnostic criteria sets. The latter is probably the most reliable way; however, even if international consensus criteria exist, there are still many different criteria sets especially for rare diseases where the superiority of one set over the other and in particular the threshold for a diagnosis remains a matter of debate. In addition, many of these criteria sets were established to obtain homogenous cohorts in clinical trials leading to a low sensitivity in early or mild disease.Another approach was the assessment of the interobserver variability by Hernandez et al.  and MartThe transferability of expert systems to the general population  can be tested with a validation in a developer-independent clinical setting. Only AI/RHEUM, CADIAG, and RHEUMA , 40, 49 Besides the internal and external validity, the following features are, according to Kawamoto et al., highly associated with an expert system's ability to improve clinical practice: the availability at the time and location of decision making, the integration into clinical workflow, and the provision of recommendations rather than a pure assessment . The widKolarz et al.  and ScheThe reason for the absence of expert systems in clinical use hitherto has been discussed in detail in the literature. Mandl and Kohane claimed that health information technology in general was in arrears compared to other industries. Also they took the health information technology products as too specific and incompatible with each other . SpreckeIn spite of computerized assistance, the user of the expert system needs rheumatologic fundamentals for the detection and the correct description of rheumatologic findings. CADIAG, AI/RHEUM, RENOIR, RHEUMexpert, and MESICAR were specifically developed for the assistance of nonrheumatologists , 48, 50.The integration of widely accepted diagnostic criteria sets such as the ACR or EULAR criteria into the diagnostic process would increase the acceptance and credibility of an expert system. It also reduces the influence of individual diagnostic strategies of the developers. Nevertheless, only six of the identified expert systems reported the integration of such criteria sets into their expert database. The downside of diagnostic criteria originating primarily from classification criteria for the inclusion into clinical trials, however, is the generally low sensitivity in early disease. This insensitivity of some criteria, such as the 1987 ARA criteria for rheumatoid arthritis, forced Leitich et al. to modify the criteria using fuzzy sets to gain different levels of sensitivity . The recAlthough a thorough systematic search has been performed in the most relevant databases, some reports could have been missed if written in other languages than English or German. As most of the current literature is published in English at least as an abstract, we are confident that we did not miss relevant articles on diagnostic expert systems in rheumatology. The number of expert systems which have remained unpublished because of their expected commercial use or the abortion of the system at an early stage is hard to estimate.The reported expert systems showed a great variety in diseases spectrum, methodology, and validation status. This made a statistical comparison of the systems impossible.And finally, the important topic of patient reported outcomes which are of increasing importance not only in clinical trials and patient's follow-up but also in the diagnostic process was beyond the scope of this review.In conclusion, this systematic review shows that the many attempts made for an ideal expert system in rheumatology in the past decades have not yet resulted in convincing validated tools allowing for reliable application in daily practice. Nevertheless, the demand in support by expert systems is pressing as the knowledge about the rheumatic diseases increases and the therapeutic options especially in early disease stages are growing constantly. An ideal diagnostic expert system in rheumatology would have the following characteristics. The expert system would allow for universal integration into the clinical workflow as well as rapid and intuitive data input. Since rheumatologic diagnoses cannot always be definite, the resulting diagnosis would have a probabilistic grade to indicate uncertainty. The system would also have an educational component to improve the nonexpert's ability to recognize pathological findings. Finally, accepted diagnostic criteria sets would be applied to increase the general validity of the system's diagnostic process.Based on the demand of such a tool and the progress made hitherto it seems to be a matter of time until new and promising expert systems enter clinical practice.


Overall, we observed a rich and diverse set of spontaneously produced analogical comparisons. The high degree of expertise within the observed group along with the richly comparative nature of the economics discipline likely contributed to this analogical abundance.The use of analogy is an important component of human cognition. The type of analogy we produce and communicate depends heavily on a number of factors, such as the setting, the level of domain expertise present, and the speaker's goal or intent. In this observational study, we recorded economics experts during scientific discussion and examined the categorical distance and structural depth of the analogies they produced. We also sought to characterize the purpose of the analogies that were generated. Our results supported previous conclusions about the infrequency of superficial similarity in subject-generated analogs, but also showed that distance and depth characteristics were more evenly balanced than in previous observational studies. This finding was likely due to the nature of the goals of the participants, as well as the broader nature of their expertise. An analysis of analogical purpose indicated that the generation of concrete source examples of more general target concepts was most prevalent. We also noted frequent instances of analogies intended to form visual images of source concepts. Other common purposes for analogies were the addition of colorful speech, inclusion  of a target into a source concept, or differentiation between source and target concepts. We found no association between depth and either of the other  The importance of analogy has been described in many ways by notable researchers. Polya  wrote thin vivo and in vitro studies to fully understand biological phenomena, Dunbar  behaviors are unconstrained by laboratory conditions and are not instigated by artificial or experimental stimuli, (b) the setting emphasizes processes rather than outcomes, and (c) there is a clear relationship between observed behaviors and the domain of interest , (b) regional refers to a source mapped from a similar domain , and (c) local maps a target to a source in the same domain. Both local and regional classes are collectively referred to as within-domain, or within-category. Because of the subjective nature of judging domain distance between similar domains, many observational studies simply categorize analogies using a binary choice of within-category or outside-category. Analogies formed within the same category might compare biological organisms or investment strategies, while commonly referenced domains for outside-category analogies include sports  and the supernatural .A second important feature in analogy use concerns the range, or . Dunbar  defined Research on the domain separation of analogies has provided contrasting results. Dunbar's studies of scientific reasoning set in microbiology laboratories showed heavy use of within-category analogies—98% of the analogies generated were classified as either local or regional Dunbar, , 1997. AOne explanation for the difference in domain distance is that the collective expertise of the audience may influence the selection of analogy. When addressing other domain experts with specialized knowledge, within-category analogs may prove more effective whereas an outside-domain analogy might be more attractive choice for a general audience. The type of task or function performed by the analogizer is another possible constraint. Our second goal was to observe the use of within- and outside-domain analogies produced by the economics experts. We expected to find a fairly balanced use of both styles, which differs somewhat from earlier findings. Our expectation was motivated by the different subdomains and varying levels of subject expertise within the reading group. Furthermore, in light of the stated belief that within-domain analogies tend to involve a higher degree of superficial similarity than outside-domain analogies, we investigated whether such a relationship emerged.Thirdly, past research has shown that the goal of the individual producing the analogy is likely to influence the process of selection and transfer  weekly reading group at The University of Texas at Dallas during the Spring semester of 2011. Participants included male and female reading group attendees. The average weekly attendance was approximately 20 participants, which included both faculty members (~25%) and graduate students (~75%). The group was largely the same from week to week, but attendance did fluctuate and not all participants attended regularly. Participants' academic expertise was mixed, and included sub-disciplines such as econometrics, experimental economics, and game theory. A few of the attendees had no exposure to experimental methods.The sessions were conducted in typical reading group fashion. One of the senior faculty members acted as the group's moderator, and one student participant was assigned each week to lead the following week's discussion of one or more chosen research papers. Following a brief presentation of the paper by the assigned student, a free and open discussion followed in which the members of the group examined and dissected the experimental methods and results described in the paper.The investigator attended and made audio recordings at each of five group meetings, but did not participate in the discussions and appeared to have minimal impact on group interaction. Group members understood that their discussions would be evaluated (the moderator referred to it as “the science behind the science”). The research goal of examining the spontaneous use of analogies was not revealed, however. Although each session was scheduled to last for 90 min, actual discussion times ranged from 65 to 110 min. In all, approximately 7 h of discourse were recorded.Four transcribers participated in the initial processing of the discourse—the primary author and three undergraduate Psychology students. Only the primary author and one of the undergraduates had any significant transcription experience prior to the task. None of the undergraduate transcribers had exposure to Economics beyond introductory coursework. Transcribers were given instruction by the primary author on what constitutes an analogy based on the definitions presented earlier in this paper, then solved practice problems on recognizing analogies from non-analogies by identifying sources and targets. The period of instruction lasted approximately 30 min.For purposes of indoctrination, each undergraduate transcriber was given one of the sessions for practice and directed to process at least 30 min of the recording. They were instructed to transcribe passages in which a possible analogy was made, taking care to include all of the important source and target information. Their instruction was: “when in doubt, include it.” The primary author evaluated their performance and made individual adjustments until the results were satisfactory and consistent.To address the possibility of subtle, easily-overlooked analogies, every audio recording was processed by two transcribers. To be included for analysis, a passage needed only to appear on either transcriber's log, not both. In order to be missed, a passage would have to have been heard by both transcribers and rejected.The two authors performed the coding duties. Both were experienced coders with strong knowledge of analogy literature and considerable research experience. Each of the transcribed segments was first evaluated for the presence of one or more analogies based on the definition stated earlier. Comparisons based only on literal similarities were considered non-analogies. If a segment was judged to contain no analogy, no further evaluation was performed. If an analogy was deemed present, the source, target, source domain, and target domain of the analogy were recorded. Each analogy was then coded along the three dimensions of distance, depth, and purpose.within-domain and outside-domain categories. Following the example of Saner and Schunn . See Appendix A for a sampling of extracted passages. When judging whether a passage contained an analogy, the coders agreed on 96% (n = 109) of the 114 passages. Of these, most were rated as containing an analogy . Passages lacking the basic ingredients of an analogy  or showing evidence of a literal comparison  were eliminated. Five passages were inconclusive and were likewise eliminated. The inter-rater reliability for identifying analogies was strong (κ = 0.85). Some of the passages were found to contain multiple analogies. In all, 97 analogies were extracted for the remainder of this analysis.Transcription of the five recorded sessions yielded 114 unique passages with possible analogies (n = 88) of the 97 analogies. Of these, analogies showing no obvious overlap in surface characteristics  far outnumbered those where superficial similarities were present . The inter-rater reliability was found to be substantial (κ = 0.75).In coding for analogical depth, the coders agreed on 91% (n = 83) of the 97 analogies. Of these, within-domain  and outside-domain  analogies were almost evenly distributed. The inter-rater reliability was again found to be substantial (κ = 0.71).In coding for analogical distance, the coders agreed on 86% , Inclusion (indicating that the target was a type or component of the source), Example (indicating that the target was an instance of the source concept), Visualization (intended to create a picture or image in the mind of the audience), Emotion , Critique (using the source to point out shortcomings in the target), Exaggeration (gratuitous use of colorful phrasing), and Abstraction . Where an analogy plausibly served multiple purposes, the raters chose the strongest.n = 77) of the 97 analogies. Examples were the most prevalent , followed by visualizations . A fair number of exaggerations , inclusions , and differentiations  were observed, but abstractions  and critiques  were uncommon. The inter-rater reliability for analogical purpose was substantial (κ = 0.74).In coding for analogical purpose, the coders agreed on 79%  and within-domain  analogies. The superficial analogies were likewise split between outside-domain  and within-domain . It was determined that there was no significant distance-depth association [χ2N = 75) or structural-visualization analogies . Though the distribution of purpose ratings was highly skewed, it was skewed similarly over both categories of analogical depth and no significant depth-purpose association was found [χ2N = 71). On the other hand, when an analogizing by example, a source-target transfer from within the same domain was most commonly observed .In contrast to the two findings above, an examination of analogical distance as a function of the speaker's purpose did reveal a significant association [χThe most prominent observation to come from this study was that the use of analogy for exploration and explanation among economics experts and students was rich and abundant. In 427 min of discourse, 97 analogies were extracted, suggesting that analogies are both commonly used and serve as an important component in human reasoning and in understanding problems. The reading group setting enabled the observation of actual experts spontaneously forming analogies using their semantic knowledge applied to economics, a domain likely to entail more freedom to move between and among domains of knowledge than the previously investigated biology and political domains. The selection and fluid assembly of analogies during discourse may help to reveal the core principles involved in analogical thinking among experts. This study's findings will be discussed in the context of prior evidence.We chose to study behavioral economics experts in this study. Economists seek to broadly explain complex real-world human behavior in the context of equations, models, games, and hypothetical examples. All of these techniques rely heavily upon comparisons between different states of the world, different types of behavior, and combinations of models and situations. While some feature or object-based similarity occurs in comparisons between economic models and real-world behavior, it can be argued that the majority of the comparisons are about relations and systems of relations. For example, in the economic Ultimatum Game , but within-category analogies accounted for a sizeable portion of the total as well (47%). These results fall squarely between the previous findings, but a plausible explanation can be made. If the number of within- and outside-domain analogies is a function of expertise, then the balance between them might be expected to vary with the range and depth of expertise. In the EPPS reading group, the participants all had some degree of expertise in economics, but their domain experience varied in terms of sub-discipline  and academic career longevity . Hence, common expertise is likely to be an influencing factor, as Dunbar suggested, but the amount of influence it has on source distance may moderated by the variability in such factors as range and depth. Additionally, the goals of the participants differed from those in earlier studies. Here, the participants sought to comprehend papers describing experimental methods and results, often by comparing unfamiliar methods to known, more familiar ones. To accomplish these goals, perhaps a more balanced and diverse set of analogies is most effective.Another possibility for explaining the balance between within- and outside-domain analogies that we observed is concerns the economics discipline itself. In Dunbar's , 1997 biIn terms of a possible relationship between distance and depth, it has been suggested that within-domain analogies present more superficial similarity than distant analogies; in other words, the greater the distance, the less superficial the comparison  and non-discovery  activities. The primary difference in purpose between the economics reading group and groups observed in the cited studies was the absence of discovery goals in the reading group. Since we determined that the discussions we observed were largely non-discovery in nature, we focused on categorizing the extracted analogies into groupings based on the perceived reason for selecting the particular analogy; e.g., to differentiate a concept from other concepts, to inject emotion or colorful language into a comparison, to give a concrete example of a more abstract idea, etc. The list we derived can be found in the Results section above.It is fairly well established that goals influence the production of analogies Dunbar, . Prior sBlanchette and Dunbar  providedIn interpreting our results, we should mention that the categories we developed were not mutually exclusive; e.g., an analogy intended to differentiate between concepts might do so using visual elements. In cases where an analogy plausibly served multiple purposes, the raters chose the category they felt best described its purpose.We have already emphasized that the collected passages contained a wealth of analogies rich in depth and structure, many of which involved implied systems of complex relations that could not be fully identified and analyzed. Furthermore, some of the more complex comparisons actually involved multiple analogies at different distances and depths. The challenges we faced in terms of analyzing the passages were made more difficult due to the complexities of the structural and superficial analogies used. Unlike laboratory tasks, in which comparisons between explicit statements are made . Second, the rating process involved some inherent subjectivity; even though inter-rater reliability was rather high, there were disagreements on specific passages. This is a challenge inherent in real-world analogical analyses, as the dynamic and unscripted nature of the interactions can produce text that is very difficult to interpret outside of the context in which it was spoken and by an individual who does not have access to the speaker's intent. Third, the rating process was further complicated when analogies were embedded in familiar language constructs—well-known clichés, common metaphors, etc.—and were not immediately identified as analogies by the raters, as such phrases have become so conventionalized that their figurative qualities can be simply overlooked.We were able to ascertain some of the major purposes for which analogies are used in economics discussions among experts. The leading purpose for analogical comparisons was to provide examples. Good examples from other domains or familiar sources can provide clarity to a target and make the concept more concrete. In many of the analogies, we observed that experts tended to either relate an abstracted theoretical model to a more common situation that occurs in human interactions, or they did the reverse and described a particular situation as being an example of what is known to occur within a particular theoretical game. Experts also made common use of analogies to create a visual image of a particular concept. Visualization is important for providing a common ground for the audience and for making a target domain richer and easier to comprehend. Experts also used analogies in order to add color or interest to their contributions and to mark a topic as being included within a more familiar source domain. Given that we conducted this observation process in an academic setting, our experts may have developed tendencies to use analogy due to their experiences with teaching, in which good examples and visual comparisons can be useful for conveying concepts (Richland et al., In addition to these questions, several limitations with regard to the method and analysis of this study should be noted. The transcribers were non-experts in economics, but they were chosen to avoid domain bias and reduce the tendency to add their own interpretation to the passages. Additionally, three of the four transcribers lacked prior transcription experience in recognizing analogies, which opened the door for subtle analogies to be overlooked. We addressed this limitation using a two-phased training process and a two-person extraction strategy and believe that we reduced - but may not have eliminated - the likelihood of missed analogies. While it is possible that some subtle analogies may have been overlooked, we believe the number to be small enough to not alter our findings.Their lack of domain expertise, however, may have contributed to the subjectivity and inconsistency mentioned above. Furthermore, we did not code the analogies according to any sort of standard domain taxonomy, as Dunbar  did in hIn summary, this study reinforces the strong reliance humans place on analogies for developing understanding and communicating in natural settings. It contributes valuable evidence that humans are quite agile in their selection of analogies, drawing on a mix of shallow and deep comparisons and determining an effective distance strategy based on the constraints of the domain and the level of perceived group expertise. Economics faculty and graduate student experts engaged in scientific discussion were observed to apply analogies that were more balanced in terms of categorical distance and structural depth than those observed in other natural settings. The domain context, problem-solving goals, and participant expertise of this particular group setting all appear to be important factors that led to differences in the magnitudes of depth and distance observed in the earlier studies. No evidence of an association between the distance and depth characteristics was found, but distance and purpose appeared to be related. A number of other questions remain to be answered about the ways in which analogies are applied in different types of settings. Future naturalistic analogy research could help to clarify the role on analogical comparisons in real-world settings and the social sciences appear to provide particularly rich domains for additional studies.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Objectives: to examine perceived age discrimination in a large representative sample of older adults in England.Methods: this cross-sectional study of over 7,500 individuals used data from the fifth wave of the English Longitudinal Study of Ageing (ELSA), a longitudinal cohort study of men and women aged 52 years and older in England. Wave 5 asked respondents about the frequency of five everyday discriminatory situations. Participants who attributed any experiences of discrimination to their age were treated as cases of perceived age discrimination. Multivariable logistic regression analysis was used to estimate the odds ratios of experiencing perceived age discrimination in relation to selected sociodemographic factors.Results: approximately a third (33.3%) of all respondents experienced age discrimination, rising to 36.8% in those aged 65 and over. Perceived age discrimination was associated with older age, higher education, lower levels of household wealth and being retired or not in employment. The correlates of age discrimination across the five discriminatory situations were similar.Conclusion: understanding age discrimination is vital if we are to develop appropriate policies and to target future interventions effectively. These findings highlight the scale of the challenge of age discrimination for older adults in England and illustrate that those groups are particularly vulnerable to this form of discrimination. The population in England and other countries continues to age due to a decrease in fertility coupled with an increased life expectancy. With people living longer, age discrimination is likely to gain greater prominence, which in turn has important implications for social protection, access to health and other public services, and securing the human rights of the older population. A key aspect that separates age discrimination from other forms of discrimination or unfair treatment is that everyone is potentially at risk of experiencing it at some point in their lives . The terThe extent of the problem in the UK is difficult to establish, since high-quality evidence from large-scale representative population surveys of older people is limited. Questions about age discrimination have been included in Eurobarometer surveys , 4, but Discrimination is thought to have a profound effect on the wellbeing of the individual , 9. PercThe majority of previous research—predominantly from the USA—has focussed on experiences of perceived discrimination in general and its association with race and ethnicity –17. ThosData were drawn from Wave 5 (2010–11) of the English Longitudinal Study of Ageing (ELSA). ELSA is a longitudinal panel survey of ageing and quality of life among men and women aged 50 and older living in private households in England, which commenced in 2002–03 . The samWave 5 of ELSA was the first to include questions on experiences of discrimination. These were based on the items developed and used widely in other longitudinal studies in the USA, notably the Health and Retirement Survey (HRS) and the Midlife in the United States (MIDUS) survey , 22, 23.You are treated with less respect or courtesyYou receive poorer service than other people in restaurants and storesPeople act as if they think you are not cleverYou are threatened or harassedYou receive poorer service or treatment than other people from doctors or hospitalsRespondents were asked about the frequency of five discriminatory situations as follows: ‘In your day-to-day life, how often have any of the following things happened to you?’Possible response options ranged from 1  to 6 (never). The responses were dichotomised to indicate whether or not participants had experienced discrimination in the past year (a few times or more a year vs. less than once a year or never), with the exception of the fifth item which was dichotomised to indicate whether or not respondents had ever experienced discrimination from doctors or hospitals . A follow-up question asked respondents to indicate what reason/s they attributed their experience to in any of the five discriminatory situations. Possible options included: age, gender, race, weight and physical disability, and participants were able to select more than one reason. Participants who attributed any experiences of discrimination to their age are treated in our study as cases of perceived age discrimination.We included age, sex, wealth, education, marital status and current employment status as covariates. Age was split into four categories: 52–59 years, 60–69 years, 70–79 years and a final group combining all those aged 80 and over. Wealth is regarded as the best indicator of socioeconomic resources in ELSA, and was measured at the household level. It was divided into quintiles for the purpose of analysis. Education was measured by the highest educational qualification attained and divided into three groups: low , intermediate  and high . We coded marital status into four categories: single, married or remarried, separated or divorced and widowed. Current work status indicated whether or not a respondent was currently employed, retired or in another situation, for example, unemployed or looking after the home or family.χ2 tests to assess the relationship between perceived age discrimination and individual covariates, and multivariable logistic regression analysis to estimate the odds ratios of experiencing perceived age discrimination adjusting for all covariates. The discriminatory situations were analysed in separate models to identify the significance of different sociodemographic characteristics. Interactions between age and wealth were also tested. A cross-sectional design weight was applied to all analyses to correct for non-response.All analyses were conducted using STATA 12. The primary outcome was the perception of age discrimination in any of the five discriminatory situations. The secondary outcomes were perceptions of age discrimination in each of the five situations. We used P < 0.001). The results also indicated that current work status was an important correlate of age discrimination. Employed respondents were shown to be 25% less likely to report age discrimination in comparison with those who were retired.We found that approximately a third (33.3%) of all respondents experienced age discrimination, rising to 36.8% in the aged 65 and over. The descriptive analyses indicated that all the sociodemographic factors with the exception of marital status were related to perceived age discrimination. Overall, perceived age discrimination was more common in male, older, less wealthy, more educated and retired respondents. The multivariable analyses showed that perceived age discrimination increased with age, peaking in the 70–79 age group , but that the sex difference was no longer significant  of this national cohort of men and women aged 52 and older experienced age discrimination, with rates increasing to 36.8% among respondents aged 65 and over. We found that perceived age discrimination was associated with older age, and was also associated with higher levels of education, lower levels of household wealth and lack of paid employment. Of the five individual discriminatory situations measured, perceived age discrimination was more prevalent where people were treated with less courtesy (17.7%) and least where people experienced harassment (4.6%). The analysis of the individual discriminatory situations revealed many similar associations, with level of education, and wealth being the most significant correlates regardless of the discriminatory situation itself.The level of perceived age discrimination reported here is comparable with a number of previous studies outside the UK. An analysis of European Union countries found that 26% of people aged 62 and over had frequently or sometimes experienced age discrimination . StudiesThis study revealed somewhat counterintuitive results for the relationship between perceived age discrimination and the two indicators of SES, wealth and education. In common with previous studies, we observed a negative gradient between perceived age discrimination and SES, with individuals in the lowest wealth quintile more likely to experience age discrimination in comparison with wealthier respondents , 18, 22.et al., this could be a result of individuals in employment perceiving old age to begin later in comparison with individuals who are retired or not working for other reasons [Our findings also indicate that respondents who were retired reported perceived age discrimination more than those who were employed. This is consistent with analysis of data from the UK, which found that working status was a strong correlate of age discrimination, with a larger proportion of respondents who were not working or were retired reporting age discrimination in comparison with those employed full time . As sugg reasons . Contrar reasons , 19, 25.Our analyses of the individual discriminatory situations revealed rather low rates of actual harassment, which could suggest that older people are regarded as less of a target by younger generations. Eleven per cent of respondents reported being thought of as less clever because of their age. This might reflect the negative old age stereotype in which older people are regarded as incompetent. The findings from these two discriminatory situations could be seen as reinforcing the persistence of the old age stereotype where older people are regarded as both warm and incompetent . Our stuCaution is needed when interpreting these findings. First, it is not possible to establish causal relationships in this cross-sectional study. We do not know whether older people are more likely to experience discrimination because of their age or whether they are more likely to attribute discrimination to age as they get older. Second, the measures of discrimination used were self-reported and therefore subject to recall bias. Third, the questions were designed to measure age discrimination in the context of other sources of discrimination, and therefore may not be optimal. However, a more targeted measure may prime respondents to answer in a particular way, whereas in our study, age was not the apparent focus of the items. Finally, respondents were able to attribute more than one reason to their experiences of discrimination; therefore, it is not possible to establish for certain whether an individual situation was due to age discrimination or another type of discrimination.Nevertheless, what this study has been able to show though is that age discrimination is encountered in the day-to-day lives of many older adults in the UK and that it is an area that needs to be studied further in order to improve our understanding of the mechanisms through which it impacts upon the individual and society. The fact that age discrimination has been shown to affect a high proportion of individuals in later life is relevant to public policy. Understanding age discrimination is important if we are to develop appropriate policies and to target interventions effectively.Approval for all the ELSA waves was granted from the National Research and Ethics Service (NRES).There is limited evidence from large-scale representative population surveys of older people on the extent of age discrimination in England.It is important to understand the potential scale of age discrimination, as it has a profound effect on the wellbeing of the individual.Frequent or occasional age discrimination is experienced by approximately a third of older adults in England.Sociodemographic characteristics associated with perceived age discrimination are older age, lower household wealth, higher levels of education and being retired or not working compared with being employed.None declared.National Institute of Aging in the United States, and a Consortium of UK Government Departments Coordinated by the Office for National Statistics. The developers and funders of the English Longitudinal Study of Ageing and the UK Data Archive do not bear any responsibility for the analyses or interpretations presented here. I.R. is supported by an Impact PhD studentship from the International Longevity Centre-UK (ILC-UK) and University College London. A.S. is funded by the British Heart Foundation.The English Longitudinal Study of Ageing was developed by a team of researchers based at the University College London, National Centre for Social Research and the Institute for Fiscal Studies. The data were collected by the National Centre for Social Research. The funding is provided by the


A number of EEG studies have investigated the time course of brain activation for biological movement over this last decade, however the temporal dynamics of processing are still debated. Moreover, the role of direction of movement has not received much attention even though it is an essential component allowing us to determine the intentions of the moving agent, and thus permitting the anticipation of potential social interactions.In this study, we examined event-related responses (ERPs) in 15 healthy human participants to light point walkers and their scrambled counterparts, whose movements occurred either in the radial or in the lateral plane. Compared to scrambled motion (SM), biological motion (BM) showed an enhanced negativity between 210 and 360ms. A source localization algorithm (sLORETA) revealed that this was due to an increase in superior and middle temporal lobe activity. Regarding direction, we found that radial BM produced an enhanced P1 compared to lateral BM, lateral SM and radial SM. This heightened P1 was due to an increase in activity in extrastriate regions, as well as in superior temporal, medial parietal and medial prefrontal areas. This network is known to be involved in decoding the underlying intentionality of the movement and in the attribution of mental states. The social meaning signaled by the direction of biological motion therefore appears to trigger an early response in brain activity. Biological motion (BM) has received much attention over the last decades and a number of studies have demonstrated that moving organisms are processed rapidly and efficiently. In fact, just a few points of light placed at the principle joints of a moving body suffice for a viewer to immediately recognize that the pattern of motion belongs to an otherwise invisible human being  and allotowards the viewer , the middle occipital gyrus  and the lingual gyrus . In the temporal lobe, greater activations of adjacent nodes were located in the middle and superior temporal gyri , and in the parietal lobe  the major activated structures encompassed the precuneus . Two other significant clusters included a large portion of the middle frontal gyrus  in the frontal pole, and the cingulate gyrus .As shown in the peak analysis of the P1 component, its amplitude was significantly greater for radial compared to lateral direction only in biological motion condition. The paired comparison between those two conditions at the P1 revealed the existence of several significant clusters situated in different areas . The maj15 = 5.27, p < .0001) and the insula . In the temporal lobe, the major group of clusters was located in the superior temporal gyrus ; whereas, in the occipital and parietal lobes, the lingual gyrus  and the precuneus  were the structures most activated . We found that BM produced a greater N1 and further observed that the increased negativity was maintained between 210 and 360ms in what we call here the early sustained negativity. More importantly in this study, biological motion showed a differential response depending on the plane of movement, with radial BM producing an enhanced P1 compared to the 3 other conditions.The effect of BM on the ERPs corroborates several previous observations. As noted above, the presence of a long, negative going potential in response to biological motion was reported by Hirai et al.  who showsustained negativity. These two periods are nevertheless clearly different, as highlighted by our topographic segmentation procedure that distinguished the N1 and ESN as distinct scalp topographies, which in turn suggests the activation of dissimilar brain networks for these two periods. In the light of our findings, we would surmise that the N1 might reflect the processing of body shape and of direction of motion as distinct processes that are not yet integrated, in view of the fact that each process was significant as a main effect. ESN on the other hand appears to reflect the processing of biological movement per se. However, very recently, White et al. [greater for scrambled than upright and inverted stimuli in contradiction with previous reports. On the other hand, no components were found to respond specifically to biological motion, thus questioning the existence of an ERP marker for biological motion. The authors therefore concluded that the ERP effects observed in initial studies must in fact reflect the integration of action and form perception rather than biological motion alone, with both processes being closely linked. This conclusion cannot be corroborated by our study, as neither static nor inverted stimuli were included in the experimental paradigm.Our findings of an N1 followed by an ESN are in line with these previous observations of two negative components. In our case, this later negativity did not possess a clearly identifiable peak leading us to use the term e et al.  contesteInterestingly, an earlier time period for BM has also been suggested in other reports ,42,43,44Using ERPs, Krakowski et al.  evidenceOur current finding therefore confirms the importance of the ESN as the time window during which biological motion is processed. This interpretation is further strengthened by the sLORETA solutions, which revealed notably an activation of the superior temporal gyrus and superior temporal sulcus when contrasting BM with SM. These anatomic locations agree perfectly with studies using brain imaging techniques that have repeatedly shown the implication of the posterior STS for point light stimuli compared to scrambled or inverted ones ,47,48,49The main focus of the current study was specifically to investigate whether brain processing was affected by the direction of biological motion , with radial motion being taken as a sign of intent , as opposed to lateral motion. A possible confound may exist in that radial and lateral motion could produce different neural response profiles occurring independently of intent. However, the earliest effect of direction was seen as an increase in P1 amplitude for radial biological motion, while radial scrambled motion and both lateral movements remained similar. Since radial BM differed from radial SM, it seems unlikely that this early modulation was linked to radial motion per se, but rather it appears to be specifically linked to this plane of motion when it is viewed in conjunction with biological characteristics. Consequently, we would argue that the P1 is indeed specific to biological radial motion, which is distinctive in that it bears socially meaningful information. Along these lines, a previous investigation, focusing on EEG oscillatory suppression, investigated mu oscillation suppression  while participants viewed BM . The stiOur current results thus provide novel experimental evidence that the neural response for radial motion is rapid and enhanced in comparison with lateral motion or with motion that is non-biological, most likely because it conveys information that may be relevant for the viewer’s survival.The analysis of the P1 generators revealed that radial BM produced a significant increase in activity in the visual striate and extrastriate regions, the fusiform and lingual gyri, the superior and middle temporal gyri, the precuneus and inferior parietal, and finally the prefrontal and cingulate regions. Interestingly, activation of these regions has been observed in studies investigating movements displaying a social component. In fact, Saxe et al.  even hypSimilarly, an implication of the medial prefrontal cortex, as well as the precuneus was confirmed for social aspects of movement by Iacoboni et al. . They coA high degree of overlap can be seen between the regions identified in our study and those established in the investigations reported above. We would surmise that the regions activated during the P1, including the medial prefrontal cortex, the superior temporal cortex, the precuneus and the extrastriate areas, all more highly activated for radial movement compared to lateral movement, are in fact involved in the interpretation of meaningful, social aspects of biological motion. Critically, our findings show a rapid and early emergence of this activity in the course of visual processing.The presence of STS sources during the P1  may seem to be somewhat early. Indeed, although intracranial responses of neurons in the STP region of the macaque have been observed at 100ms , the sizThe results of this investigation show that radial biological motion enhances the early P1 component, an effect that is not observed for radial scrambled motion or for lateral biological motion. The LORETA source localization algorithm points to a significant increase in the activity of generators associated with the attribution of mental states and of intentionality during this early stage. On the other hand, biological motion, irrespective of direction, is processed at around 210ms to 360ms seemingly by the superior temporal region. Socially relevant motion thus appears to be processed very early in the course of brain activation.To summarise, we speculate here that the processing of biological movement is closely intertwined with the processing of the intentions of the moving agent. As directionality contains highly relevant information concerning the objectives and intent of the moving agent, it is an essential element in preparing for interactions with other individuals and therefore possibly threatening situations. We would conjecture that evolution has implemented neural mechanisms that lead to rapid integration of directional information, allowing us to detect the motion of a person along the radial plane and to respond accordingly. Future investigations should include radial motion of non-human biological organisms in order to determine whether these effects are present in social situations alone, or whether they are triggered more generally by the movement, and potential threat, of any living animal.


Congenital hearing loss is the most frequent birth defect. The American Academy of Pediatrics and the Joint Committee on Infant Hearing established quality of care process indicators for Universal Newborn Hearing Screening starting from 1999. In a previous systematic review of Universal Newborn Hearing Screening studies we highlighted substantial variability in program design and in reported performance data. In order to overcome these heterogeneous findings we think it is necessary to optimize the implementation of Universal Newborn Hearing Screening programs with an appropriate application of the planning, executing, and monitoring, verifications and reporting phases. For this reason we propose a conceptual framework that logically integrates these three phases and, consequently, a tool (a check-list) for their rationalization and standardization.Our paper intends to stimulate debate on how to ameliorate the routine application of high quality Universal Newborn Hearing Screening programs. The conceptual framework is proposed to optimize, rationalise and standardise their implementation. The checklist is intended to allow an inter-program comparison by removing heterogeneity in processes description and assessment.The online version of this article (doi:10.1186/s13052-016-0223-1) contains supplementary material, which is available to authorized users. Sensorineural hearing loss is one of the most frequently occurring permanent congenital defects at birth with a prevalence of 0.1–0.3 % for newborns   programs   to evaluWith the aim to verify whether literature reporting experiences on hospital-based UNHS programs include sufficient information to allow inter-program comparisons according to the already available indicators/benchmarks defined by the AAP and JCIH, we performed a systematic review . We founIn order to overcome these heterogeneous findings we think it is necessary to optimize the implementation of Universal Newborn Hearing Screening programs with an appropriate application of the planning, executing, and monitoring, verifications and reporting phases. For this reason we propose a conceptual framework that logically integrates these three phases and, consequently, a tool (a check-list) for their rationalization and standardization.Deliver the protocol Action is activated, apart from the first instance, if the benchmarks are not achieved, if guidelines/recommendations are updated, or if the context specificities change. The output of this phase is the protocol for UNHS execution.A planning phase based on indications from guidelines and recommendations, specificities of the local context, benchmarks, reports from verification phase. The An executing phase where the protocol is applied and where data should be generated and managed for monitoring. The outputs of this phase are the raw data for process monitoring.Monitor action is activated periodically or upon request to aggregate data and build performance indicators. The verification is made comparing indicators with benchmarks and a report is generated with an analysis of reasons for possible deviations which can push for a redefinition of the protocol and/or for a re-organization of its execution. Reports can be used also for disseminating purposes.A monitoring, reporting and verifying phase where the The framework is structured on several phases .A more detailed description of the single phases follows in the following sections  or are pulation ).The audiological risk criteria are relevant for that: specific audiological risk may require a specific screening protocol; the timing and number of hearing re-evaluation (surveillance) for infants at risk should be customized and individualized depending on the relative likelihood of a subsequent delayed onset hearing loss.The typology and the number of tests, and the healthcare setting in which performing the examinations (before or after the discharge) – The program needs to be well balanced for sensitivity, specificity, coverage of the population and costs per subject identified. E.g., Kennedy et al. [The presence of specific protocol for neonates at higher risk  [. The set of examinations for the full audiological evaluation – E.g., the one recommended by the JCIH [The tasks to be performed to increase the percentage of enrolment and to reduce the lost to follow up (neonates referred to further examinations that do not show at the planned appointments) - With reference to the former, it has to be noted that specific actions should be done for an appropriate communication with families creating the conditions for an informed consent. With reference to the latter, a survey conducted in USA [The surveillance program for early identification of infants and children with late onset  – It is recommended to perform regular surveillance of developmental milestones, auditory skills, parental concerns, and middle-ear status to for all infants, together with an objective standardized screening of global development, at 9, 18, and 24 to 30 months of age or at any time if the health care professional or family has concern [The cooperation among all the involved operators, services and institutions - The identification of the key roles is an essential step for an appropriate management of the entire process and for monitoring purposes.Activities, detailed actions, decision nodes, workflows, roles, environmental conditions have to be identified and specified. More specifically key issues are reported. y et al.  reported TEOAEs)  - Such nthe JCIH . The tasd in USA  shows thd in USA  that sta concern . The cooUniversality– completeness of universality in both recruitment and follow-up phases;Timely detection– specification of follow-up deadlines for identification and intervention, and determination of the observed prevalence;Overreferral – Efficient use of highly specialized care.In our systematic review  the AAP For each reported indicator a reference benchmark has been identified  which reMonitor, Verify and Report Activity and it is used to make process results explicit and, as previously reported, as the basis for possible re-planning and/or reorganization.This is the output of the The proposed framework has been used as a conceptual guidance for building a checklist (Additional file As reported in the 2007 JCIH Position Statement , regularThe paper is a contribution toward a standardisation in reporting UNHS experiences which may favour the emerging of best practises.