Present and future of non-invasive peripheral nervous system (PNS)–Machine Interfaces  was convened, hosted by the International Conference on Rehabilitation Robotics. The keyword PMI has been selected to denote human–machine interfaces targeted at the limb-deficient, mainly upper-limb amputees, dealing with signals gathered from the PNS in a non-invasive way, that is, from the surface of the residuum. The workshop was intended to provide an overview of the state of the art and future perspectives of such interfaces; this paper represents is a collection of opinions expressed by each and every researcher/group involved in it.One of the hottest topics in rehabilitation robotics is that of proper control of prosthetic devices. Despite decades of research, the state of the art is dramatically behind the expectations. To shed light on this issue, in June, 2013 the first international workshop on  Present and future of non-invasive PNS–Machine Interfaces took place in June, 2013 in Seattle, USA, hosted by the 13th International Conference on Rehabilitation Robotics (ICORR). The keyword peripheral nervous system (PNS)–Machine Interface  was chosen to denote one of the hottest topics in the rehabilitation robotics community, namely the interpretation of biological signals extracted non-invasively from the PNS, with the intent to equip an individual with disability to reliably, dexterously, and naturally control a robotic artifact gifted with many degrees of freedom (DOFs).The first international workshop on In the paradigmatic case, surface electromyography (sEMG) is used as the main source of signals, and the complexity of modern upper-limb prostheses  represents a formidable challenge and an ideal benchmark for the PMI dealing with the problem. sEMG has been in use since the 1960s to proportionally control single-DOFs hand grippers since it involves neither surgery nor hospitalization, its signal remains rich in information even decades after an amputation, and it provides clearer signals than brain–computer interfaces based upon, e.g., electroencephalography. The application of machine learning to sEMG has been proposed since the 1960s as a means of converting electrical activation signals to useful control signal for arm and hand prostheses; nevertheless, the state of the art of control is still poor.Literally dozens of different approaches have been applied to sEMG to decode an amputee’s intentions, but none has as yet made it to the clinics: as a PMI, sEMG has revealed to be unreliable, badly conditioned, subject to change with time, fatigue, and sweat. No valid alternatives to sEMG are used in the clinics, whereas dexterous prosthetic artifacts are now appearing on the market, demanding ever better control by the patient.The workshop revolved around four “themes” or “questions,” with the aim of shedding at least a partial light on some of them:(1) what is wrong with sEMG? why do clinicians not use it?(2) how can sEMG be better used?(3) what alternative, radically new solutions are available, if any?(4) what are the benefits of sharing control between the human subject and the prosthesis?Ten invited talks were given at the workshop, in which each research group gave a broad overview of its activities and offered its point of view on one of the above topics. This paper collects the opinions appeared in the workshop.The remainder of the paper is organized according to the four above questions; an overview of the talks, as well as a presentation of the workshop and of the PNS–MI workgroup, can be found at the URI pnsinterfaces.wordpress.com.Merkur Alimusaj, Levi Hargrove, Todd Kuiken, and Rüdiger Rupp.The benefit and acceptance of myoelectric prostheses are influenced by a number of reasons: weight, noise, cosmetic appearance, battery duration, price, and expense of servicing. State-of-the-art mechatronic devices  aim to increase the number of motorized DOFs available. To make full use of these multifunctional prosthetic systems an appropriate user interface must be implemented. Several research groups are working in the field of sEMG pattern recognition, trying to create a more robust prosthetic control by adding predictors into control schemes. Although a lot of work has been done, only marginal progress has been made in the clinically available solutions for prosthetic control. A bigger effort is therefore needed to address the prosthesis user’s needs within multidisciplinary projects. This leads to the necessity of putting the user at the center of the research and shaping research to target clinical relevant outcomes.Loss of a hand or an arm due to an amputation dramatically decreases the quality of life. The amputee has not only lost her/his grasping functions, but also an important communication tool. Not only amputees, but also patients with congenital deformities are prosthetic users and should therefore be addressed. Since the human hand/arm has more than 20 DOFs, the idea of a complete substitution by a prosthesis represents a highly ambitious goal.Figure 1 shows the typical harness implanted on a patient of shoulder disarticulation.The dexterity of current prosthetic effectors is not yet anywhere near that of the human upper limb. The lack of functionality and intuitive control increases by the level of amputation – most dramatically at the level of shoulder disarticulation or four-quarter amputation; in such cases the usage and acceptance of currently available upper extremity prostheses is dramatically low , mainly The replacement of a human hand by means of a prosthesis already poses a number of challenges from the mechatronic point of view. However, the control issue might be even harder . This leTargeted muscle reinnervation (TMR) transfers the residual motor branches of arm nerves to alternative muscle sites , while sTMR was developed primarily to create independent EMG control sites for proximal level upper-limb amputees. TMR is also suitable for other amputations levels. For example, analysis of high-density surface EMG signals shows that information corresponding to intrinsic hand-muscles may be decoded using pattern recognition . Our cliSimultaneous and proportional control of more DOFs has highest priority in research and clinical routine . AccordiIn addition to the developments in pattern recognition and surgical intervention, relevant effort has been spent on the improvement of motion prediction , i.e., aFigure 2).One of the major limitations of current devices is the lack of feedback to the user about forces or position of the prosthesis. To achieve an intuitive and reliable control, feedback must be provided . FeedbacMost of the research in the field on advanced prostheses is currently carried out in robotics/electrical engineering laboratories. Like in other fields of assistive technology, the introduction of an iterative user-centered design is needed to establish a close link between researchers, clinical experts, professional, and end-users. The feedback of end users on the usability of complex prostheses developed by engineers and robotic specialists would help to come up with devices that match the user needs and capabilities; clinical evidence shows that the high variability in the population of amputees needs individual solutions, not only at the level of mechatronic components but also for the socket, the control systems, and the training. Prosthetic fitting is always dependent on the patient’s needs and individual anatomy which all should be addressed by including clinical aspects in the development process of novel devices.Future work should target the integration of additional and/or novel sensors and sEMG arrays  within tBarbara Caputo, Kevin Englehart, Arjan Gijsberts, Patrick M. Pilarski, and Eric Scheme.robustness, adaptability, and situational awareness of myoelectric control systems and other human–machine interfaces . As a whole, the studies reviewed in this section suggest that, by increasing the decision making and information processing capacity of sEMG control technologies, it may soon be possible to surpass many of the existing barriers to their use in a clinical setting.In light of the observed limitations to conventional myoelectric control, a number of approaches have been developed to more effectively process and use existing myoelectric control information. In particular, enhanced pattern recognition and other forms of machine intelligence have been recently deployed to increase the Pattern-recognition-based myoelectric control has been discussed in the research literature for decades  but has Each of these studies indicated a need for a more comprehensive representation of the usage case during training. This suggests that the common approach to classification validation in the literature  yields only a sparse population of the discriminatory feature space. This sparsity, typically combined with highly repeatable experimental conditions, has led to the observation that the selection of classifier has a minimal effect on the overall system performance . Incorpon motions is predisposed to fail as more challenging usage scenarios are introduced and more sources of variability are added. Instead, the myoelectric control task may more naturally lend itself to a detection problem, where the presence of a known/desired signal is not guaranteed. This subtle difference in philosophy accommodates the notion that observed active myoelectric signals may not result from an intention to activate the prosthesis – current pattern-recognition-based systems, however, do not consider this scenario; rather, the assumption is made that all active contractions originate from a desire to activate the prosthesis, resulting in inadvertent movement of the device during aberrant, accidental, or stabilization contractions. Further complicating the matter is the discrete nature of pattern classification, which gives no indication that patterns are changing until an error actually occurs. This greatly limits the ability to anticipate changes in the system and to measure the influence of confounding factors.Another criticism of pattern-recognition-based approaches has been a perceived lack of visibility into its inner workings . Some grno movement decision. The introduction of this rejection option complicates the oﬄine quantification of performance because the effect of the tradeoff between false activations and excessive rejection is unclear. Instead, using a real-time Fitts’ law style virtual target achievement test  was introduced that converted its nonlinear probability outputs into usable confidence scores . These cent test , a signiWhile their work  focused One of the main goals of the biorobotics community is to develop hardware and software tools for providing amputees with dexterous, easy to control prosthetic hands. Still, as of today we live a dichotomy between the hardware and software capabilities of such devices. While today’s hardware for robotic hands has reached impressive levels, control over a satisfactory range of hand postures and forces is still coarse. Progress in the field has often been slowed down by the lack of public data collections. Until 2012, only a limited set of data for hand prosthetics was available. Mostly, such proprietary databases contained up to 10 different grasping actions, static hand postures or fingers and wrist movements.NinaPro database .A key point underpinning work on real-time machine learning for PMI control is that contextual or situational awareness  is important for improving and adapting myoelectric control systems . This viongoing use of a human–prosthesis interface via techniques from reinforcement learning  for a designer to model prior to deployment. Continued work is this area will enable a move toward more advanced, persistent machine intelligence in PMIs and other assistive technologies.Claudio Castellini, William Craelius, and Michael Wininger.Attempts to use sEMG signals for volitional control of advanced prostheses have not met with universal success, due in part to the fact that each central command propagates via variable transmission pathways to diverse muscles lying both superficially and deep, that act both synergistically and antagonistically, and in part to the fact that sEMG is labile to environmental factors endemic to the socket, i.e., moisture. The mechanical actions of the end-effectors, however, are better surrogates for volitions, since they embody trajectory, speed, and force directly, and are insensitive to upstream variability , and obvIn the quest for novel peripheral interfaces, recently  medical In carrying the ultrasound transducer and the machine along; as it stands at the time of writing, the current technology forbids the complete miniaturization of such a device. Nevertheless, smaller and cheaper ultrasonographers are being built and marketed by the main manufacturers basically every year. On the other hand, more immediate applications are those in which the immensely richer information gathered from US imaging would really help. Firstly, wherever it is not strictly necessary to miniaturize the machine, although fine control is required; for instance, aboard a robotic wheelchair, or to control a robotic setup in the domotic framework . In such cases, related to patients with highly reduced mobility, US imaging could help, in that extremely tiny musculoskeletal changes could be fully detected and interpreted.All in all, from these results it seems that US has a future in the midterm run, but not as a direct competitor to sEMG. The main drawback remains the necessity of Secondly, US imaging could be used in a hospital as a day-care therapy for rehabilitation. Since every hospital in the Western world has nowadays access to ultrasound imaging (and the proposed approaches are irrespective of the characteristics of each single machine), it is imaginable to have muscle- and nerve-impaired patients, e.g., stroke and ALS patents, amputees, etc., attend periodic meetings to work out virtual-reality rehabilitation tasks. For instance, a virtual piano-playing application or the imitation of a visual model moving its arms and hands. The therapy could be finely tuned to each single patient. This therapy could be seen as a follow-up to mirror therapy .In both cases, and in particular if and when US-based control is required for a somewhat longer time than what is usually enforced in standard US examinations, it will be necessary to first investigate the effects of continuous ultrasound beams on the human tissues. US imaging is so far deemed harmless, but more testing in harder conditions is very likely to be required. Summing up, the usage of US imaging as a peripheral human–machine interface is being explored and is a promising alternative or complement to more portable – but less accurate – PMIs.Signatures of the soft-tissue  response of an upper-limb amputee can be represented as forces exerted by the entire residuum against the prosthetic socket. Volitions are thus encoded as topographic force maps (TFMs) that can be registered via a variety of pressure sensor arrays . Like ulTopographic force maps registers the 3D volume changes of the residuum are registered as a dynamic map of muscle recruitment. This measurement is made via force-sensitive resistors (FSRs), which change resistance according to force application normal to its sensor face. The FSR sensor comprises a resistive element printed onto a thin, flexible polymer, with a sensing head dimension as low as 5 mm diameter (3 mm active area). While the FSR material is not waterproof, the FSR’s manufacturer  is ideally suited for placement within a waterproof enclosure.Previous work with the FSRs in prosthetic sensing have placed them in a variety of arrangements: embedded in silicone or fabric, in direct- and indirect contact with the skin. In studies with generic sensor placement, the TFM technique shows high accuracy in predicting the basic movement parameters associated with isometric grasp, both in free- and targeted tasks ; this suTopographic force maps produce fast and accurate control over several independent DOFs by upper-limb amputees . AdvantaThe practicality of TFM, and its limitations in terms of number of DOFs, and applicability to types of amputation, remains to be proven, since it has only been a laboratory technique thus far. Whether and to what extent this constrains the utility of TFM – and whether sEMG or any other detection modality has a greater likelihood of capturing these subtleties – remains to be seen: it may be that the enhanced stability of the TFM signal reduces the caprice as multifunction hands and wrists become more widely accessible . ClearlyTopographic force map has not yet been tested in scenarios where grasp volition is to be decoded throughout a heavy lifting task. The socket and residuum are not rigidly connected, so placing a heavy weight in the prosthetic hand would shift the weight distribution across the surface of the limb, and would unload some sensors while increasing load on other sensors. This presents a unique signal decoding challenge not faced in EMG or US, and presents a need for further development in TFM.Arash Ajoudani, Panagiotis Artemiadis, Antonio Bicchi, Strahinja Dosen, Dario Farina, Sasha Blue Godfrey, Mark Ison, Marko Marković.Recently, the prosthetic devices have evolved greatly, significantly growing in complexity from simple, single DOF grippers to highly dexterous systems providing individual finger control. However, the actual potential of these systems still remains largely under-utilized in daily life applications, as the current state-of-the-art PMIs cannot accommodate the emerging complexity of the system control. Conventionally, the development of PMIs has been driven mostly by the advances in the acquisition and processing of myoelectric signals, with the classical master–slave myocontrol being the most common command interface. In this traditional control setup, the prosthetic device (slave) “listens” for the muscle activity and then translates the user (master) intentions into actions. Here, we advocate a different approach that is based on developing systems which are capable of autonomous decisions making and independent, automatic operation, while at the same time sensing the environment and communicating with the user via a range of feedback interfaces.Figure 7), such a system comprises: (1) a processing unit  implementing control algorithms; (2) a sensing interface  providing information for the autonomous decision making; (3) a feedback interface  communicating the state of the system to the user; (4) an upper limb prosthesis ; and (5) a user command interface  providing high- and low-level manual control. The key features of the system are: automatic operation, bidirectional communication, semi-autonomous, and closed-loop control. Using a simple command interface, the user triggers the system operation. The PU acquires and analyzes the data from the sensing interface and then, independently from the user, commands the prosthesis to perform autonomous actions, such as, pre-shaping and orienting the hand to perform the grasp. Simultaneously, the PU uses the feedback interface to communicate the control decisions  as well as the current state of the prosthetic device  to the user, thereby closing the control loop. The user can exploit this information to supervise the system operation and, when needed, take over the control to fine tune and/or correct online the automatic decisions of the artificial controller . Therefore, the control is shared between the user and the artificial controller, where the latter effectively shields the former from the low level execution details and thereby significantly decreases his/her cognitive burden (semi-autonomous control).In its general form : (1) object targeting: the user looks at the object he/she would like to grasp. The computer vision is used to segment the scene and identify the targeted object. The system acknowledges the successful identification to the user by covering the object with a transparent overlay ; (2) automatic hand pre-shaping: the user triggers the system indicating the intention to grasp the selected object. The controller determines the properties of the target object (shape and size), and based on this information, employs cognitive like processing (rule base) to decide grasp type and size suitable for the object. The hand is automatically preshaped and AR feedback communicates the selected grasp parameters to the user. The grasp type is shown as a visual icon in the peripheral visual field while the aperture size is depicted in the form of a virtual box placed next to the target object, where the size of the box corresponds to the amount of the hand opening; (3) user corrections the user evaluates the outcome of the automatic control  by consulting the AR feedback and if needed adjusts the prosthesis preshape by issuing simple sEMG commands ; (4) object manipulation: once the preshape is adjusted, the user issues the command for the prosthesis closing. The system was successfully evaluated in an experiment with 13 healthy subjects operating a prosthesis mounted on the forearm using a custom made splint , and a high level processing (cognitive-like reasoning) to achieve fully automatic control of the functions that are conventionally the responsibility of the user  and at various self-selected levels of cocontraction (for stiffness mapping). In preliminary testing with five intact control subjects, normalized root-mean-square error rates of 17.6 and 13.4% were calculated for each synergy, respectively. Ultimately, parameter identification for these models in amputees is likely possible through various training methods such as mirror-box, teacher imitation, or mental imagery .Figure 10) and an intermediate ramp-up time was required to reach these forces (data not shown). The adaptability of the teleimpedance controller produced more favorable interactions with everyday objects: the stiff controller often resulted in object deformation when used to grasp more compliant objects, whereas grasps with the compliant controller were likely to slip despite adequate molding around the object. Another method to share control is to close the loop by providing feedback to the user. Because the human hand is capable of perceiving a variety of signals from temperature to surface texture to pressure, etc., in providing feedback to assist control, it is difficult to reproduce the full range of the hand’s sensory information. In preliminary testing, we have focused on feeding back grasp force to the user via vibrotactile motors . However, placing the full burden on software prediction currently leads to more user frustration due to the aforementioned intensive training sets and limited prediction accuracy placing upper-bound constraints on user performance  and non-intuitive  mapping functions . AlthougFigure 11), but train their motor system to develop unique muscle synergies associated with the full system dynamics of the myoelectric device . Recent work  has showFigure 12). The system dynamics include not only the mapping function, but also disturbances from electrode placement and shift, limb position, and unique movement patterns, resulting in a robust control of the full task space. The developed synergies have common population-wide components, and their continuous refinement correlates with a long-term learning component that increases both performance and control efficiency over time during consistent, repeated use. Moreover, it is found that these synergies are maintained after periods of non-use, allowing subjects to retain a significant amount of performance on familiar tasks and generalize upon the introduction of new tasks within the same control space. The user then has freedom to increase control efficiency simply by interacting with the device to adaptively identify the system dynamics relating neural activity to the given, novel task space. The ability to retain and refine unique synergies and utilize them to generalize control to the entire task space supports the use of synergy development, not necessarily user-specific trained decoders, for efficient myoelectric control of robots designed for long term use.Although these studies have only evaluated learning through visual interfaces, Both studies suggest that users can be trained to control a multiple DOF myoelectric prosthetic device with minimal frustration, simply by interacting with the specific mapping function. In the case of amputees, especially TMR patients , there iThere is clearly no definite answer to any of the questions posed as the motivation for the workshop, but the opinions expressed in this paper are at least indicating a direction in which to go. Here is a list of recommendations for the future research in PMIs.Research in PMIs is still essentially a matter of the academic community of rehabilitation robotics and machine learning; this means that the level of practical involvement of the scientists in the clinical environment is inadequate. The research focusses too much on the mathematics and the mechatronics and tends to neglect the final target, that is the patient. The clinicians involved in conceiving, designing, and fitting the prostheses and instructing the patients are still highly unsatisfied with the tools they get; this calls for a major change in the research perspective, which must be transferred on the field, namely, the hospital, or even at home, since the beginning.A further theme which was not treated in the workshop is that of providing real-time feedback to the patient. So far, this branch of the PNS–MI topic, i.e., the feedback path, seems much less explored than its feedback counterpart. Nevertheless, the feedback path would definitely improve the feeling of embodiment, therefore strengthening the “reciprocal learning” effect, and overall enhancing the control. Subsequent editions of the workshop will take this issue into account.The tendency of machine–learning-based myoelectric control schemas to output unstable control signals is still a major issue, mostly caused by the inherent instability of biological signals. There are several suggestions to counter this problem. First and foremost, in the machine learning community there is still a dangerous tendency to claim that approach A is better than approach B on the basis that A achieves a better classification rate, whereas most of the times the classification rate is evaluated using the same dataset gathered oﬄine , an idioSecondly, machine–learning-based control is still, by and large, discrete and sequential, meaning that one DOF can be controlled on–off at each point in time (classification); as opposed to this, simultaneous and proportional control should be enforced. In this schema, one real-valued control signal is simultaneously available for each of the DOFs of the mechanical artifact. Each control signal should be independently controlled by the patient, possibly in the natural way , and short training should be enforced by devising a way to combine the single DOF activations into more complex patterns. It is clearly unacceptable to have the subject show the system, e.g., each and every grasping pattern.Thirdly, novel PMIs should be used to improve the intent detection enforced by sEMG. There are indications that ultrasound imaging and topographic force mapping are viable approaches; computer vision for the estimation of the action to be taken, the development of new muscular synergies and the delegation of grasping to a lower-level closed-loop control are also interesting paths ahead.Most amputees will not feel that the prosthesis is their own hand, notwithstanding the well-known properties of adaptation shown by the human brain. This is due to at least two factors: lack of dexterity of the prosthetic devices  and lack of feedback to the subject, let alone the need to improve the control, shorten the reaction times, and miniaturize the systems to be onboard. Ownership and immersion, the feeling of self with respect to the device, is in fact the ultimate goal.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.


In this paper, the numbers of refugees travelling to the European Union are set in a global context. It is argued that the increasing restrictions placed on asylum seekers from the 1980s onwards in the UK and the associated culture of deterrence and prohibition have had the perverse effect of supporting the economic market for people smuggling. It appears that these restrictions were initially designed to deter people, most of whom would have been granted humanitarian assistance had they managed to arrive in the UK, so as to prevent them from accessing the decision-making process on asylum. Policy changes concerning travel, benefits, and other pressures on asylum seekers are also considered in the context of deterrence. The problems facing asylum seekers do not end with their arrival in a safe country. The current methods of determining refugee status are alarmingly weak. Indeed there is evidence suggesting that those who are most traumatised before arrival face systematic disadvantage. The focus of this paper is on the United Kingdom but its conclusions apply to most Western European countries. The paper concludes with some tentative suggestions for change. Recent news stories have highlighted the plight of refugees travelling into Western Europe across the Central Mediterranean and, more recently, across the Eastern Mediterranean and through Hungary. Frontex  estimates that in 2012, 15,151 migrants travelled across the Central Mediterranean; these numbers grew to 45,298 in 2013 and 170,664 in 2014 Frontex, . The UniThey are often transported across the Mediterranean by people smugglers—in boats that are not fit for the journey, overcrowded, and frankly dangerous. Following the death of 368 refugees off Lampedusa in October 2013, a search and rescue operation (Mare Nostrum) was launched. This was scaled back in December 2014. UNHCR reports that in the first 3 months of 2015, 479 refugees and migrants drowned or went missing, as opposed to 15 in the first 3 months of 2014. In April 2015, 1,308 refugees and migrants drowned or went missing in a single month UNHCR, .People smuggling is simply defined as the procurement for financial or other material benefit of the illegal entry of a person into a state of which that person is not a national or resident . By the end of 2014, Syria had become the world's top source country for refugees, overtaking Afghanistan, which had held this position for over three decades. Despite the stereotypes so common in the media, relatively few refugees find their way to Western Europe. There are different ways of looking at the data UNHCR, . Simply Displaying the data with reference to the size of the host population  demonstrUNHCR also provides a measure of impact taking into account per capita income of the country . This ilSo the data clearly indicate that most refugees find their way to neighbouring, often relatively poor countries, rather than to Western Europe.In this paper, the focus will be on the UK. This is not because it is necessarily better or worse than other European countries but simply because the situation in the UK is better known to the author. To put the UK data in context, in 2014 Germany received 202,645 asylum seekers, Sweden received 81,180, Italy received 64,625, France received 64,310, Hungary received 42,775, whereas the UK received only 31,745 , by 1989, the largest number of asylum seekers were from Turkey  on humanitarian grounds  to seek asylum. Neumayer  has undeWithin Europe, some countries appear more popular than others (at different times). Research studies undertaken separately on behalf of the UK government  rather than refugees themselves, it was probably naive to expect that the ending of Mare Nostrum would achieve a reduction in migration in the short term. Indeed, as UNHCR  has repoIn summary, it is likely that increasing use of prohibition tactics, closing down legal routes of entry, has had the unintended perverse result of favouring those running clandestine routes. People smuggling has become a business and those profiting from it will have their own reasons for increasing demand. Western policies of deterrence lead to more and more draconian steps being enacted to prevent access  and therefore the growth in potential profits for people smugglers.Simply arriving in a Western country, such as the UK, is not the end to the difficulties that many face. The process of determination of refugee status is also fraught with problems. This is partly because it is such a tough decision to make. The decision relies on two main factors. The first concerns the nature of the claim being made and a view as to whether it satisfies one of the legal tests; this is relatively straightforward. However, the second is to do with the credibility of the claim; this is an area where decision making becomes especially subjective and therefore amenable to influence by external factors (or even by the emotions of the decision-maker at the time). Thus in Europe, Neumayer  found thIn the USA, there has been a very large-scale audit of the decision-making process and in the subsequent report (appropriately entitled “Refugee Roulette”), the authors publish some of their findings .The authors were provided with data from all eight regional offices covering 928 US asylum officers (first-line decision-makers) over 6 years. Across all eight regions, the variation in mean grant rates in Chinese cases (to take one example) ranged from under 20% in one region to over 70% in another. However, averages like these hide the extent of the variation. In one of these regions, grant rates by individual officers varied between 0 and 68%; one officer had considered 273 Chinese cases and had not granted a single asylum claim. There was even greater variation in the decisions made by judges. For example, in Los Angeles, 22 experienced judges assessing similar Chinese cases made remarkably different decisions. One judge accepted 9% (of 117 cases) and another 81% (of 118 cases). The authors found that quality of legal representation had a profound effect on outcome. Whereas those asylum applicants who were unrepresented had a 16.3% chance of success, those routinely represented had a 45.6% chance of success and those represented by a specialist clinic had an 89% chance of success. Asylum applicants represented pro bono by large law firms had a success rate of about 96%.Curiously the judge's gender also had a bearing on outcome; female judges granting 53.8% and male judges 37.3% of cases. An asylum applicant assigned by chance to a female judge therefore had a 44% better chance of success. Previous experience of the judges—government service, military, non-profit organisations, academia, and private practice—all had a substantial effect on case outcomes. In brief, factors that should have had no impact on outcome of individual applications were surprisingly important.No similar large-scale audit of UK practice has been undertaken. However, some data are available. In the year to end March 2015, there were 25,020 asylum applications in the UK. Initial decisions appropriately varied by country of origin; 85% of initial decisions for nationals of Eritrea and Syria were grants compared with 22% for Pakistani nationals. Overall, 40%  of decisions were grants either of asylum or an alternative form of protection. There were 11,067 appeals received in the year to March 2015. Of cases heard, 28% of appeals were allowed, once again suggesting that these are not easy or reliable decisions.against the person genuinely fleeing from trauma and persecution. Bögner, Herlihy, and Brewin  and potential biases against those with a history of traumatisation.This paper does not set out to provide simple answers to what is self-evidently a complex problem. It does argue for a detailed systemic data-driven analysis and not a flight into naive political rhetoric. The evidence presented here probably favours various approaches.First, we need to recognise the large growth of migration in the world as a whole and set out to understand the reasons for this. International aid  can and should be used to support economic growth in poorer parts of the world. Policies can also support nations who are starting to make their own shift away from autocracy; implementing human rights policies, supported by an international legal framework, is likely to reduce the pressure to leave countries. Western military action, for example, in the Middle East, has often had its own adverse effects and the costs of these should be recognised from the outset, with appropriate steps built in to foster successful nation-building. Most refugees find themselves in camps in neighbouring countries and financial support for this local refugee response should be supported as a (likely) cost-effective way of making life more bearable there (a humanitarian impulse) and thereby also reducing the drive to move on to the West .Second, we need to recognise the weaknesses in the policies and systems we have set up in the West. This will be tough because public opinion currently is not always supportive. Nonetheless, we do need to start moving the argument away from “bogus asylum seekers” or “swarms of migrants” and recognise that many of those we prevent from arriving here, from countries like Syria and Eritrea, would receive humanitarian protection had they been able to travel. Current policy is often designed simply to stop migrants accessing our decision-making processes. This applies at the EU's external borders  as well as at the EU's internal borders . As with other policies of prohibition, this approach stands to favour the commercial market in people smuggling. Perhaps there is no political will in European countries to take more refugees, but there is absolutely no reason why the debate should not be open and honest. Current evidence suggests that there need to be further reforms to the Dublin regulation and more coordination of refugee reception and other policies across the European Union.Finally, we must recognise the weaknesses of the decision-making process itself. There is a pressing need for more research and for the implementation of that body of psychological knowledge that exists concerning testimony evidence and trauma. Our courts should set out to be examples of best practice in a way that they have probably not yet achieved. If we compromise on that principle with regard to asylum seekers, we stand to compromise on fundamental principles of fairness and justice for us all.


Many animal and human subjects can learn to avoid punishment or noxious stimuli by exploiting the sensory cues predicting them. In cue-signaled active avoidance (AA) learning, subjects first learn about the predictive properties of cues and subsequently learn a behavioral strategy of an avoidance response . AA learning develops with fear reduction as an intervening variable , cingulate cortex, thalamus, and auditory cortex in the acquisition and retention of AA  exerts feed forward inhibition of the amygdala to reduce the expression of freezing responses to the CS while sparing the predictive association between the CS and US, which is necessary for AA learning , it is not surprising that dopamine (DA) neurons play different roles ranging from signaling reward and mediating motivation to coding aversion, salience, uncertainty, and novelty Horvitz, . AdditioHere, we will discuss the tonic and phasic DA release associated with signaled AA. Briefly, DA antagonists impair AA responses, and electrical stimulation of reward circuitry facilitates AA . HypothThere is also evidence that CeA–DA interactions may be important for AA learning. The CeA projects to substantia nigra DA neurons and to the DLS. Moreover, electrical stimulation of the CE modulates the firing of SNc DA neurons (Rouillard and Freeman, From the above-mentioned evidences, it is clear that parallel streams of information might reach the amygdala and DA midbrain structures, and both systems might interact at the striatum level Figure . BlockinUnlike reward learning, when a subject masters AA, it no longer receives external motivation in the form of a US, providing a mystery to early learning theorists. How can behavior be sustained in the absence of reinforcement? One solution is that a fear memory of the US continues to be evoked by the CS, and alleviation of this fear state can continue to motivate the AA response in the absence of the US. But if the CS is no longer paired with the US, why does the CS–US association not undergo extinction? Moreover, animals that have mastered an AA task no longer show strong physiological signs of fear or distress. For these animals, the execution of the avoidance response takes on the quality of a habit. Therefore, we propose that AA learning ultimately recruits and depends on the same circuitry involved in habit formation, such as the so-called spiraling loop of striatal–nigral–striatal circuitry (Yin and Knowlton, 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.


This paper explores definitions of death from the perspectives of several world and indigenous religions, with practical application for health care providers in relation to end of life decisions and organ and tissue donation after death. It provides background material on several traditions and explains how different religions derive their conclusions for end of life decisions from the ethical guidelines they proffer.Research took several forms beginning with a review of books and articles written by ethicists and observers of Bön, Buddhism, Christianity, Hinduism, Indigenous Traditions, Islam, Judaism, Shinto and Taoism. It then examined sources to which these authors referred in footnotes and bibliographies. In addition, material was gathered through searches of data bases in religious studies, general humanities, social sciences and medicine along with web-based key word searches for current policies in various traditions.Religious traditions provide their adherents with explanations for the meaning and purpose of life and include ethical analysis for the situations in which their followers find themselves. This paper aims to increase cultural competency in practitioners by demonstrating the reasoning process religions use to determine what they believe to be the correct decision in the face of death.Patterns emerge in the comparative study of religious perspectives on death. Western traditions show their rootedness in Judaism in their understanding of the human individual as a finite, singular creation. Although the many branches of Western religions do not agree on precisely how to determine death, they are all able to locate a moment of death in the body. In Eastern traditions personhood is not defined in physical terms. From prescribing the location of death, to resisting medical intervention and definitions of death, Eastern religions, in their many forms, incorporate the beliefs and practices that preceded them. Adding to the complexity for these traditions is the idea that death is a process that continues after the body has met most empirical criteria for determining death. For Hinduism and Buddhism, the cessation of heart, brain and lung function is the beginning of the process of dying—not the end. Roman Catholicism, for example, believes that death happens when the soul leaves the body; Buddhism sees death occurring at a point after the invisible, subtle consciousness leaves the physical body. Because these events are not visible, religions turn to empirical evidence to determine that death has occurred. This paper seeks to explore how religious perspectives define death and determine that it has occurred with application to end of life care and donation of organs and tissues after death. This paper develops the basic features of religious traditions and the ways in which their ethical analysis takes place. It aims to increase cultural competency in practitioners by demonstrating the reasoning process religions use to determine the correct decision in the face of death.This paper explores definitions of death from the perspectives of several of the world’s religions. Research for this explication and analysis took several forms beginning with a review of books and articles written by key ethicists in Judaism, and various forms of Christianity, Hinduism, and Buddhism. It then examined sources to which these authors referred in footnotes and bibliographies. In addition, material was gathered through searches of data bases in religious studies, general humanities, social sciences and medicine along with web-based key word searches for current policies in various traditions.The so-called “definitions” of death fall into two categories: the philosophical and the empirical. The first seek a conceptual understanding of the essential differences between life and death. The second seek to determine the clinical signs, tests, or criteria which separate life and death most accurately .In his personal statement contained within the President’s Council on Bioethics white paper on determinations of death, Edmund Pelligrino noted:The debate about the specifics of empirical definitions that began in earnest in the mid 1960’s continues today. George Khushf has noted that “in most of the current biomedical literature, the purely biological character of any death concept is simply asserted as a premise, and subsequent reflection attempts to clarify the nature of such a biological concept” .The diverse and complex religious perspectives of the world’s religious traditions on this issue has not yet been explored in the kind of detail one sees in the scientifically focused literature. Scholars have provided solid scholarship on a range of religious traditions understanding of determining death. For example, individuals such as Damien Keown  and KarmWhen confronting issues at the edges of life, religious perspectives can become especially influential because they explain the nature of the human individual, the goal of life, the reasons for death and for most, what happens after the death of the body. Because religions provide a way of interpreting the world, individuals living in the midst of a particular tradition can continue to be influenced by it even if they have stopped believing or practicing.cogito ergo sum; both place greater value on the mind and brain than on other bodily organs. Traditions that do not share these influences construe their understandings of death from sources within their cultures and faiths and can reject determinations of death that center on the brain. In the United States, two states, New York and New Jersey, have enacted legal protections for individuals holding religious views that differ from the standard definitions of death.The category of brain death that predominates in Western allopathic medical systems relies on a definition of death that emerges from a concept of the human being that is heavily influenced by ancient Greek thought and Descartes’ concept, coma dépassé in their seminal 1959 work . Belief in demons and rituals to placate them that are common in Tibetan indigenous religions are not part of this Western form. Shambhala adherents blend their own pre-existing ideas, such as ideas about the nature of body and soul, with their Buddhist views. Shambhala is eclectic and while rooted in Tibetan Buddhism it draws on other Eastern traditions religion as well . The difBlending existing ideas, incorporating the views of other faith expressions, philosophy and science, and making the religion distinctly your own is characteristic of adherents in this group. The Auckland Shambhala Center in New Zealand states: “A unique quality of the Buddhist teachings is that they can be expressed through existing cultural norms, making use of them rather than destroying or replacing them. This allows many westerners to practice Buddhism today without renouncing their cultural heritage or radically changing their lifestyles” .In his book, Preparing to Die, American Shambhala teacher, Andrew Holecek outlines the basic features of Shambhala’s interpretations of Tibetan Buddhism and draws heavily on the Tibetan Book of the Dead as one would expect. But his work takes several decidedly Western turns. He opens his book with the statement, “Don’t measure your death against any other, and don’t feel you have to die a certain way. Let your life and your death be your own. There are certain things in life we just do our own way” (:4). FocuHolecek, who writes for the Shambhala organization, views the practices of the Tibetan Book of the Dead as the most valuable in preparing for death. He carefully explains the ritual practices relating to the deceased and cautions against moving the body until three days after the heart has stopped beating. But in a major departure from Tibetan understanding and practice, he adds, “If the dead person is an organ donor, the generosity of offering their body supersedes these instructions. Organ harvesting should begin immediately.” Rather than seeing the process of dying solely in the terms explained in Tibetan Buddhism, he describes clinical death “as either (1) the irreversible cessation of all the functions of the brain, including the brain stem, and (2) as an irreversible cessation of circulation, heartbeat, and breathing”. Holecek and Shambhala as an institution, in sharp contrast to the majority of non-Western Buddhists, believe that the dying individual can overcome the difficulties in reaching the appropriate afterlife that interrupting the dying process would produce :164).Although the majority of Buddhist writing on withdrawing treatment determines that it will have harmful consequences for both the dying individual and the person who actively participates in this process, Shambhala has a nuanced view that shows Western influence. Actively killing someone, as in most traditions, is wrong because the karmic effects, even if the intent is good, will be eternal and negative. Removing life support systems, which Shambhala calls passive euthanasia, “only has a soft karmic effect that can easily be overcome”. Holecek writes, “There comes a point when there’s no need to prolong life and incur unnecessary emotional and financial burdens” (:264).Patterns emerge in the comparative study of religious perspectives on death. Western traditions show their rootedness in Judaism in their understanding of the human individual as a finite, singular creation. Although the many branches of Western religions do not agree on precisely how to determine death, they are all able to locate a moment of death in the body. In Eastern traditions personhood is not defined in physical terms. Moreover, the influence of indigenous systems on the religions of Hinduism and Buddhism is significant. From prescribing the location of death, to resisting medical intervention and definitions of death, Hinduism and Buddhism in their many forms, echo these indigenous traditions. Adding to the complexity for these two traditions is the idea that death is a process that continues after the body has met most empirical criteria for determining death. For Hinduism and Buddhism, the cessation of heart, brain and lung function is the beginning of the process of dying—not the end.Although not all members of a given tradition will believe or practice in the same way, they are often guided by the religious perspectives which surround them. In times of crises, and the death of a loved one is surely such an event, even the agnostic might summon long forgotten symbols, rituals and prayers and draw comfort from them.ddIn his book, The Sacred Canopy, sociologist of religion Peter Berger wrote, “The power of religion depends, in the last resort, upon the credibility of the banners it puts in the hands of” its followers “as they stand before death, or more accurately, as they walk inevitably toward it” .aThis comparative exploration is narrowly focused on which criteria different religions find appropriate when determining death. It does not include a discussion of patients in a persistent vegetative state; no religious tradition considers such a patient dead.bIn non-Western traditions, the absence of a heartbeat and/ or respiration would be a signal that the process of death was beginning; it would not indicate that death had occurred.cRabbi and physician, Moses Feinstein initially opposed the definition of death developed by the Harvard criteria; later he came to embrace it. His views are shared by others including Gedalia Schwartz, Moshe Tendle and the chief rabbinate of Israel.dBleich is joined in his perspective by other revered Rabbis including Hershel Schachter and Mordechai Willig.eThe italicized section is Rabbi Moses Isserles’ gloss on Joseph Karo, Shulhan Arukh, Yoreh Deah 339 that was completed in 1563.gSee for example, Mackler A: Life and Death Responsibilities in Jewish Medical Ethics. New York: The Jewish Theological Seminary of America; 2000.h For the bioethicist, he adds knowledge of science.iThe Church of Christ Scientist, (Christian Science), was founded by Mary Baker Eddy in 1879. As an institution, Christian Science does not approve of any medical intervention, hence it has no pronouncements on moral issues that involve medical treatment. Individual Christian Scientists are free to make their own decisions.jWere there church pronouncements, they would not be binding on the members of these groups except in the case of Jehovah’s Witnesses. Blood transfusions are specifically and absolutely prohibited because of what this group sees as a clear Biblical mandate against them. Partaking of a transfusion will have, in their view, eternal consequences and will lead to an individual being disfellowshipped from their organization.kJehovah’s Witnesses are not allowed to receive bone marrow transplants because of the possibility of transplanting blood. Transplant surgery from living or cadaver donation is allowed if the surgery is bloodless. Organ donation is encouraged.lThis web-site of this Association lists the following members: Advent Christian General Conference, Assemblies of God, Baptist General Conference, The Brethren Church , Brethren in Christ Church, Christian & Missionary Alliance, Christian Catholic Church , Christian Church of North America, Christian Reformed Church in North America, Christian Union, Church of God , Church of God, Mountain Assembly, Inc., The Church of the Nazarene, Church of the United Brethren in Christ, Churches of Christ in Christian Union, Conservative Baptist Association, Conservative Congregational Christian Conference, Conservative Lutheran Association, Elim Fellowship, Evangelical Church of North America, Evangelical Congregational Church, Evangelical Free Church of America, Evangelical Friends International of North America, Evangelical Mennonite Church, Evangelical Methodist Church, Evangelical Presbyterian Church, Evangelical Missionary Fellowship, Fellowship of Evangelical Bible Church, Fire Baptized Holiness Church of God of the Americas, Free Methodist Church of North America, General Association of General Baptists, International Church of the Foursquare Gospel, International Pentecostal Church of Christ, International Pentecostal Holiness Church, Mennonite Brethren Churches, USA, Midwest Congregational Christian Fellowship, Missionary Church, Inc., Open Bible Standard Churches, Pentecostal Church of God, Pentecostal Free Will Baptist Church, Inc., Presbyterian Church in America, Primitive Methodist Church, USA, Reformed Episcopal Church, Reformed Presbyterian Church of North America, The Salvation Army, Synod of Mid-America (Reformed Church in America), and the Wesleyan Church.mIn 1988, The Lutheran Church in America merged with the American Lutheran Church and the Association of American Lutheran Churches to form the Evangelical Lutheran Church in America. Together with the Lutheran Church Missouri-Synod and the Wisconsin Synod, they comprise the largest three forms of Lutheranism in the United States.nThe split between the two main divisions of Islam, the Shiite and Sunni occurred shortly after Islam was founded. Though these two groups can diverge widely on many theological and practical issues, they do not differ in general on the issue at hand despite the rift between them.oHadith is the narration of the teaching of the prophet transmitted by those who heard him. The Sunnah is the code of practices taught by the Prophet.pThus a brain dead patient can inherit and the spouse is not widowed.qThe authors note that individuals who are less traditional will have views that are more moderate.rHome in this context seems to mean variously, the location of the family unit and the actual dwelling place. See also [See also  429-431.sOther reasons are sometimes given for this; the practice varies little however.tSee [tSee  for a ditSee .uSee also [See also .vBuddhists note that consciousness may not be observable and recount stories of the Buddha and saints who were mistakenly declared dead when they were in a meditative trance. See also [See also .wChan Buddhism developed, in part, because some Buddhists believed Pure Land to be overly simplistic. Chan is not focused on a heavenly paradise but is a meditative school focusing on developing the individual self. Pure Land Buddhism is highly popular in China; Chan appeals more to people in the West.xSee [xSee . Japan hyThe origins of Tibetan Buddhism are unclear. There are features of Hinduism and both Chinese and Indian Buddhism in the tradition found in Tibet.zThe actual title is Bardo Thodol; it is typically translated as the liberation through hearing during the intermediate states.aaTsomo’s work has been influential in the wider Buddhist community. Buddhist scholar Damien Keown, once one of the few Buddhist proponents for accepting neurological criteria in determining death, has now changed his position after being asked to review Tsomo’s book on Buddhism and bioethics . Koethics .bbNot all convert practitioners of these traditions are alike, however. American born Tibetan nun and Buddhist scholar, Karma Lekshe Tsomo exemplifies the convert who holds firmly to the original form of their new tradition. Tsomo’s form of Tibetan Buddhism closely resembles what one might find in Tibet and indeed she studied there.ccWestern Zen Buddhism offers many resources relating to death and dying but these do not include discussions about determining death or withdrawing treatment. See the website of the Upaya Zen Center located in Santa Fe, New Mexico [w Mexico .ddThe controversy about, confusion with, and difficulty with neurologically based definitions of death in Japan illustrates this. Scholars from several fields have discussed the reasons for resistance in Japan; Jīro Nudeshima proffers the theory that the difficulty arises from distrust of the medical profession while philosopher Ominé Akira argues that animism is at the root of the controversy [troversy . Margaretroversy .


The Visceral Adiposity Index (VAI) has recently proven to be an indicator of adipose distribution and function that indirectly expresses cardiometabolic risk. In addition, VAI has been proposed as a useful tool for early detection of a condition of cardiometabolic risk before it develops into an overt metabolic syndrome. The application of the VAI in particular populations of patients  has produced interesting results, which have led to the hypothesis that the VAI could be considered a marker of adipose tissue dysfunction. Unfortunately, in some cases, on the same patient population, there is conflicting evidence. We think that this could be mainly due to a lack of knowledge of the application limits of the index, on the part of various authors, and to having applied the VAI in non-Caucasian populations. Future prospective studies could certainly better define the possible usefulness of the VAI as a predictor of cardiometabolic risk. The BMI is wrongly considered a satisfactory predictor of the percentage of body fat, and it is known that it shows a curvilinear and not a linear association with the body fat percentage in both men and women .Beyond the criticisms recently leveled  towards  Lancet in 2006 [Also, in 2005 in JAMA Katherine Flegal published one of the first studies  to analy in 2006 , evaluatThis is a condition which deep-down does not appear desecrating to those who are concerned with prevention of cardiovascular disease: in fact the BMI does not appear in any of the versions of the algorithm of Framingham, one of the strongest tools for defining coronary and cardiovascular risk. Indeed, in the Framingham study it was assumed that there could be “metabolically healthy obese subjects.”An important contribution to evaluation of the influence of obesity on cardiovascular risk is the Interheart Study , which sThese data incontrovertibly seem to support the usefulness of the evaluation of waist circumference (WC) in cardiovascular risk stratification, having been considered the most valid index of regional distribution of adipose tissue. Measurement of body circumferences, although it is a valid method, requires an accurate performance method in order to provide reproducible information. Several studies have shown that WC is strongly related to visceral fat and abdominal adiposity, more than BMI and waist/hip ratio.The only limitation of WC is inaccurate distinction between visceral and subcutaneous adipose tissue in the abdominal region.The Visceral Adiposity Index (VAI) is an empirical-mathematical model, gender-specific, based on simple anthropometric (BMI and WC) and functional parameters (triglycerides (TG) and HDL cholesterol (HDL)), and indicative of fat distribution and function . It is a2, TG in mmol/L, and HDL in mmol/L.At first a model of adipose distribution (MOAD) was created based on this linear equation , before it develops into an overt metabolic syndrome and/or a cardiovascular complication. Unfortunately, today there are still no long-term prospective studies that allow us to evaluate the predictive power of the VAI regarding cardiovascular risk.Our first study on the VAI , in a poAlthough the VAI was modelled on a Caucasian population, several studies confirm the validity of its use with other races. For example, in a large case-control study, a high VAI is associated with elevated risk of CHD in Chinese men and women . MoreoveDespite this suggestive evidence, there are also conflicting data like those shown by an Iranian study, which concluded that using the “complex” VAI, instead of other simple anthropometric measures, may lead to loss of much information needed for predicting incident CVD . AnotherIn the hepatological field, the VAI has been investigated in several studies in patients with NAFLD, with the main objective of identifying a clinical marker predictive of evolution towards necroinflammatory injury and fibrosis –25. In tIt is now known that carbohydrate, lipid, and protein metabolism and the whole cardiovascular system respond to multiple endocrine signals, including those originating from the adipose endocrine organ. Therefore, there are several endocrine diseases that expose the patient to a significant cardiometabolic risk. This risk is unfortunately not easily identifiable through the classic systems of valuation  based on classical cardiovascular risk factors. Nor, in this field, can one rely on the presence of obesity; it is now known that endocrinopathy may increase cardiovascular risk even in lean subjects. Therefore, especially in young patients with endocrine disease, who have not yet developed an overt metabolic syndrome, the application of the VAI could give useful information.2 and a VAI > 1.675 have similar diagnostic value in detecting adverse metabolic profile in women with PCOS, a risk that according to AES and BMI > 27 kg/m2 criteria tends to overestimate the problem; therefore, given the simplicity of WC and BMI measurement and TG and HDL assessment, it has been suggested that the VAI could be an easy and useful tool for the assessment of MU-PCOS in daily clinical practice and in population studies [Insulin resistance and abdominal obesity are common but not universal features of PCOS, and they are not always associated with an increased BMI. Indeed, many studies have shown that both lean and obese women with PCOS have insulin resistance , though  studies .β-cell function [Untreated acromegalic patients have a decreased fat mass and increased lean body mass due to the lipolytic effect of GH , 38. In function . This pafunction . In anotfunction  the VAI Much is known about the effects of prolactinomas on the reproductive system, but few data are yet available regarding metabolism and adipose tissue function. However, in both men and women alterations have been observed in the distribution of adipose tissue, probably related to chronic hyperprolactinemia , 43. In The application of VAI in overt Cushing's syndrome, on the basis of the typical clinical and phenotypic alterations of the disease, is probably not very useful. The fact is that almost all patients with overt Cushing have a pathological increase in waist circumference, BMI, and triglycerides and lower HDL cholesterol. In these patients (who for the reasons indicated above present a high VAI), the use of the index adds nothing to simple application of the metabolic syndrome criteria. Furthermore, if on the one hand the VAI is probably an indicator of adipose dysfunction, on the other hand it is known that all patients with Cushing have visceral fat dysfunction. In our opinion, the only application field of the VAI in Cushing's syndrome is epidemiological studies with a high sample size, taking into account the well-known limits of the index. In a recent study, the VAI was tested in 140 patients with Cushing's syndrome ; in thisThe scientific evidence of the last three years on the use of VAI has allowed us to understand the usefulness of the index and especially also its limitations. These have been summarized in a recent letter to the journal NMCD . The maiAnother important aspect that deserves to be investigated concerns changes in the VAI with a low-calorie diet. Theoretically a healthy weight loss achieved with a mildly reduced calorie-balanced diet (which does not result in intense and rapid lipolysis), possibly accompanied by aerobic physical activity, should result in a reduction in the VAI. This aspect has not yet been studied. An original recent study found that Ramadan fasting in healthy adult men was associated with significant decreases in body weight, BMI, waist circumference to height ratio (WHtR), and Body Adiposity Index (BAI), but we found no significant changes in the VAI . These dAnother important limitation to consider is the application of the VAI in non-Caucasian populations and in patients aged less than 16 years. The fact is that the numerical factors of the index arise from a mathematical modelling process on healthy Caucasian men and women, aged between 19 and 83 years. In this regard a study was recently published which evaluated the VAI in children . The aut2, patients with one or two of the 5 components of the metabolic syndrome, women with PCOS, and patients with endocrine disorders .Having made these considerations, we recommend the application of VAI in the following populations: healthy or apparently healthy population with BMI < 40 kg/mα, hs-CRP, IL-6, and IL-18) in patients with type 2 diabetes. Our data suggest that the VAI, among the most common indexes of adiposity assessment, would be an easy tool for clearly mirroring adipose tissue dysfunction and its associated cardiometabolic risk.An appropriate use of the VAI  could help us in various clinical situations to assess the complex phenomenon of “adipose tissue dysfunction," especially in the absence of an overt metabolic syndrome. Unfortunately, today the ability of the VAI to express adipose tissue function is only to be seen as a hypothesis; indeed few studies exist that have evaluated the correlation between it and adipocytokine production , 25, 41.In conclusion, although still lacking prospective studies that can attribute a prognostic role to the VAI regarding cardiovascular risk, given the simplicity of WC and BMI measurement and triglycerides and HDL cholesterol assessment, we suggest that the VAI would be an easy tool for the evaluation of adipose tissue dysfunction and its associated cardiometabolic risk in various patient populations, mainly in the absence of an overt metabolic syndrome.


The polio eradication journey in Nigeria has been long, with a mix of good and not so good news over the years. Nigeria was very close to interrupting transmission of polio and then experienced an upsurge of transmission, owing to an interaction of several factors. At one point, Nigeria became a net exporter of poliovirus to polio-free countries, but at the end of 2013 there was clear evidence that the hard work and numerous innovations that the government and its partners had implemented were beginning to pay off: the number of cases of wild poliovirus (WPV) type 1 infection had decreased by 58%, compared with 2012; there had not been any cases of WPV type 3 infection detected since November 2012; and there had also been a reduction in the genetic diversity (clusters) of WPV1, from 8 in 2012 to 2 in 2013. In 2014, there were 6 cases of WPV1 infection, compared with 53 in 2013, and the number of genetic clusters had decreased to 1.Poliovirus transmission in Nigeria has been driven by reservoirs in northern Nigeria, where several states are considered to be at very high risk of poliovirus transmission. Additionally, 3 states in the northeast region have suffered from insecurity, and this added another facet to the struggle to control polio; several health workers gave the ultimate sacrifice to polio eradication, when they were killed as they conducted their work.All public health programs rely on effective surveillance and prompt response guided by the best information available. Polio eradication, like other infectious diseases surveillance and response programs, relies on prompt detection, registration, and laboratory and epidemiologic confirmation of suspected polio cases; reporting, analysis, use, and feedback of data; and preparedness and response . Like other programs, polio eradication needs managerial and support functions, which include coordination, supervision or performance evaluation, training, and resource provision for infrastructure, including communication. In Nigeria, each of these core activities and support functions were needed for the polio eradication program to produce the remarkable results that it has achieved, given the situation that it is in. New innovations also had to be tried and perfected to solve complex problems that revolved around the community accepting incessant rounds of oral polio vaccination.This supplement presents some of the public health programmatic innovations that the Nigerian government and its polio partners, with the support of the World Health Organization, tried and implemented to interrupt the transmission of polio. The programmatic interventions that are described here include efforts to create demand for polio vaccination; strategies to detect every case of suspected WPV, including those in the environment; methods to determine the underlying population immunity; strategies to effectively plan for, implement, and track vaccination activities, using the latest technologies; and approaches to widen the polio partnership in noncompliant and security-compromised communities. These interventions were enabled by a focused effort to obtain the necessary resources, use them effectively and transparently, provide the needed public health workforce, and ensure accountability for results.In 2014, Nigeria was one of the countries that was affected by the Ebola virus disease outbreak in West Africa. This supplement reviews how the polio partnership demonstrated remarkable flexibility by addressing and quickly overcoming this major public health challenge, using lessons and experiences obtained from polio eradication without compromising the gains that had been won for polio eradication.At the time this supplement was prepared, Nigeria had gone 12 months with no report of WPV and had started using inactivated polio vaccine. We believe that these public health interventions and other activities will help Nigeria enter a poliovirus-free environment. We also believe that these lessons can be adapted to improve routine immunization in Nigeria. We hope you will enjoy learning about these interventions.


Background: Meta-research can involve manual retrieval and evaluation of research, which is resource intensive. Creation of high throughput methods  has improved feasibility of large meta-research questions, but possibly at the cost of accuracy.Objective: To evaluate the use of double sampling combined with multiple imputation (DS + MI) to address meta-research questions, using as an example adherence of PubMed entries to two simple consolidated standards of reporting trials guidelines for titles and abstracts.Methods: For the DS large sample, we retrieved all PubMed entries satisfying the filters: RCT, human, abstract available, and English language . For the DS subsample, we randomly sampled 500 entries from the large sample. The large sample was evaluated with a lower rigor, higher throughput (RLOTHI) method using search heuristics, while the subsample was evaluated using a higher rigor, lower throughput (RHITLO) human rating method. Multiple imputation of the missing-completely at-random RHITLO data for the large sample was informed by: RHITLO data from the subsample; RLOTHI data from the large sample; whether a study was an RCT; and country and year of publication.Results: The RHITLO and RLOTHI methods in the subsample largely agreed . Compliance with abstract and title criteria has increased over time, with non-US countries improving more rapidly. DS + MI logistic regression estimates were more precise than subsample estimates . As evidence of improved accuracy, DS + MI coefficient estimates were closer to RHITLO than the large sample RLOTHI.Conclusion: Our results support our hypothesis that DS + MI would result in improved precision and accuracy. This method is flexible and may provide a practical way to examine large corpora of literature. However, manually retrieving and analyzing the vast archives of written material to evaluate meta-research questions can be very time consuming and costly. The resource-intensity of this process leads many researchers to narrow the scope of inquiry in some way to answer questions of interest, which might, in principle, be explored more broadly. For example, Kaiser et al.  exploredHITLO) data. In this subsample, we can also evaluate the characteristics of interest using a less-resource intensive, but often also less accurate , method to create lower rigor, higher throughput (RLOTHI) data, and then compare these two values.One potential approach employs double sampling, where two samples are taken: a large sample and a subsample (from the large sample). The appropriate sample size of the subsample “depends on the relative costs of observing the two variables and on the strength of the ratio relationship between them ,LOTHI on the subsample alone is quick and easy, but will likely have large random and possibly systematic errors . Using the RHITLO method alone is not only more accurate but also more resource-intensive, which may not allow samples of sufficient size to offer the power and precision desired. The ability to apply the RLOTHI method to the large sample improves precision compared to the results of the subsample alone, but is still likely prone to systematic error. To avoid this problem, applying the RHITLO method to the large sample would be ideal. However, this is impractical to perform on large corpora of literature in a timely manner. Instead, we propose using the RHITLO of the subsample alongside the RLOTHI for the large sample to estimate the RHITLO of the large sample , we can estimate the large sample RHITLO values via multiple imputation  the subsample is compared with the large sample. Randomization guarantees that as the size of the full sample and of the subsample increase, any discrepancies in either observed or unobserved characteristics between the full sample and the subsample due to chance will on average shrink toward zero chance differences between the two. Multiple imputation is an approach to filling in missing data in a systematic, unbiased manner based on other data available in the dataset. The inclusion of auxiliary variables that provide additional information, such as date of publication (DP), about the missing data can help either reduce the bias or increase the power . The aim of the paper is to describe the method and illustrate its application through evaluating whether titles and abstracts adhere to two simple CONSORT guideline criteria. As shown schematically in Figure To investigate the utility of this technique, we explored two of the criteria outlined in the CONSORT guidelines. The CONSORT guidelines were created in 1996 in an effort to improve the quality of reporting for RCTs  or no country listed in the place of publication field (n = 24) were excluded .For the purpose of this study we were interested in randomized controlled trials in humans, written in the English language, and that have an available abstract. Classification of RCT status was based on the RThe subsample entries were rated on the following:For articles where Patrice L. Capers and Andrew W. Brown were uncertain whether a title and abstract were from an RCT, we assumed that PubMed was correct in identifying the entry as an RCT. Any disagreements were resolved by consensus. If no consensus could be met on the title and abstract alone, we retrieved the full article for full review.LOTHI method for the title looked for the word “random,” including variants with any prefixes or suffixes, anywhere in the title. For abstract compliance, the RLOTHI required that an abstract needed to contain words representative of at least three of four headings: Introduction, Methods, Results, and Conclusion. Understanding that a variety of descriptors are used for these subheadings , we grouped a variety of words into the proper identifier categories . The RLOTHI was subsequently applied to the entire large sample (including entries from the subsample).For title compliance, the RWe also identified the country from which abstracts were published using the PubMed place of publication (PL) tag. We used this tag to categorize papers in the following manner, based on data from the CIA World Factbook . While there was unequal representation of countries in the entries available, the distribution was similar between the large sample and the subsample . If not otherwise stated, discussion of results is about DS + MI results.HITLO method. Excluding non-RCTs, 28% of the titles were compliant with CONSORT guidelines , but resulted in false positives when non-RCTs were included (phi coefficient = 0.96). The false positives in the RLOTHI search arose from titles containing either the word “random” or “RCT” but the paper was actually a study protocol or secondary analysis of RCTs.Out of the 500 entries that PubMed tagged as RCTs in humans, only 399 were found to be actual RCTs according to the Res Table . The RLOLOTHI and RHITLO data are identical, the regressions on the subsample are identical  for both the full subsample and only RCTs within the subsample. From the subsample, 51–53% of abstracts were compliant.The consistency in ratings between the Rgh Table , but lesHITLO method. At the time of CONSORT publication, NESC abstracts were significantly less compliant than both the ESC and NESC. The significant interaction terms for ESC-by-year and NESC-by-year indicate that ESC and NESC were increasing the odds of abstract compliance faster than US . In the subsample, the larger error from the small sample size again resulted in only year being significant, with abstracts having 17.5 and 17.6% greater odds of being structured using the RHITLO and RLOTHI methods, respectively, every year beyond August 1996 . Again, the small sample size resulted in only year being a significant predictor in the subsample Table .LOTHI results and the DS + MI results, which are more similar to the subsample RHITLO results, to be evidence of improved accuracy. Specifically, when comparing the RHITLO to RLOTHI methods, similar patterns were observed between the subsample and large sample in which RHITLO estimates that were higher than the RLOTHI estimates in the subsample tended to be higher in the large sample, and vice versa. As expected, employing multiple imputation reduced the confidence intervals of those estimates compared to the subsample alone, improving precision. The reduced variance in estimates between the RHITLO and RLOTHI models were not as dramatic as we had predicted because the RLOTHI we employed was generally a highly correlated proxy for our RHITLO data, as evidenced by the corresponding phi coefficients. One would expect that with poorer correlation between RLOTHI and RHITLO, the information gained from DS + MI would improve precision considerably.Our results support our hypothesis that DS + MI would result in improved precision and accuracy of a large sample estimate. Using a double sampling approach with multiple imputation improved the precision of the point estimates compared to the subsample alone, as evidenced by the tightened confidence intervals around the logistic regression coefficients. We interpret the difference in point estimates between the RIn our illustration, we were able to demonstrate that US had significantly higher reporting compliance before the implementation of the CONSORT guidelines relative to NESC but not ESC. However, over time, both ESC and NESC have been improving reporting compliance more rapidly than US abstracts, though it appears that compliance has increased over the years for all countries. Of the two criteria, we investigated structured abstract compliance was higher, which may be the result of journal requirements that submitted manuscripts contain structured abstracts . When exHITLO results were not obtained for an entire dataset, and thus we were only able to compare the results of the subsample and rely on established statistical theory for our inferences. A key limitation is that the method will only be useful when there is some imperfect correlation between the poorer and better measurement methods that is modeled effectively in the imputation process. To the extent that the relation approaches 0 or 1, the two-stage strategy will be of limited value. So too, if the functional form of the relation cannot be modeled properly in the imputation process, the two-stage strategy may yield biased results. It is possible that use of other imputation algorithms may yield different results. It is our hope that more researchers will continue to evaluate, validate, and extend the use of this method when conducting meta-research of the scientific literature.In conclusion, using double sampling with multiple imputation allows for tractable large sample estimation for meta-research questions in situations where performing a comprehensive higher rigor, lower throughput evaluation on the entire corpus is impractical. This method is flexible and can be applied to many questions conditional on assumptions being met, namely that data are missing completely at random, expert ratings are sufficiently valid to be of intrinsic interest, that ratings comprise an exhaustive set of options, and sufficient data are collected to inform the imputation. In the presented example, the data were missing completely at random because we retrieved all available entries from PubMed based on the previously mentioned filters; expert ratings were conducted by trained, PhD-level scientists; the possible ratings for title and abstract compliance were exhaustive; and the sample size chosen for this study was appropriate to illustrate the feasibility of this method. One limitation of the present investigation is that RPLC, AWB, JAD, and DBA made substantial contributions to the conception and design of this work, the analysis, and interpretation of the data; drafted this work and revised it critically for important intellectual content; provided final approval of the version to be published; and agree to be accountable for all aspects of this work in ensuring that questions related to the accuracy or integrity of any part of this work are appropriately investigated and resolved.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.http://www.frontiersin.org/Journal/10.3389/fnut.2015.00006/abstractThe Supplementary Material for this article can be found online at Click here for additional data file.


The model was tested with a sample of 628 Spanish customers of the store Zara who had used at least two channels during their most recent shopping journey. The results indicate that the key determinants of purchase intention in an omnichannel context are, in order of importance: personal innovativeness, effort expectancy, and performance expectancy. The theoretical and managerial implications are discussed.The advance of the Internet and new technologies over the last decade has transformed the retailing panorama. More and more channels are emerging, causing consumers to change their habits and shopping behavior. An omnichannel strategy is a form of retailing that, by enabling real interaction, allows customers to shop across channels anywhere and at any time, thereby providing them with a unique, complete, and seamless shopping experience that breaks down the barriers between channels. This paper aims to identify the factors that influence omnichannel consumers' behavior through their acceptance of and intention to use new technologies during the shopping process. To this end, an original model was developed to explain omnichannel shopping behavior based on the variables used in the UTAUT2 model and two additional factors:  In recent years, advances in technology have enabled further digitalization in retailing, while also posing certain challenges. More specifically, the evolution of interactive media has made selling to consumers truly complex  and multichannel, it is important to continue investigating in the field of omnichannel consumer behavior  model  or ease of use (Innovation Diffusion Theory). According to previous studies  believe they should use different channels depending on their needs. Social influence, understood as a direct determinant of behavioral intentions, is included as subjective norm in TRA, TAM2, and TPB, and as image in IDT .We designed an online survey focused on omnichannel fashion retail customers. The questionnaire was administered to a Spanish Internet panel. For the purposes of our study, we defined www.zara.com), and then pick up or return the product at the physical store. However, the most important reason for choosing a single company to study the factors influencing omnichannel customers' behavior was to isolate the omnichannel factor, that is, we wanted to determine the drivers for using different channels and/or technologies of a single company during a single shopping process.To carry out the study we selected the company Zara for several reasons. First, Zara is one of the most well-known and important fashion retailers. Additionally, the brand follows an omnichannel strategy, allowing its customers to combine different online channels  with the offline channels throughout their customer journey. In other words, shoppers can search for information on a product using the Zara mobile app, buy the product on the Zara website  technique.The aim of this research was to explore technology acceptance and use in an omnichannel context. To achieve this aim, fundamentally, theory development, we chose to use the PLS technique to evaluate the structural model before testing the causal model. Next, we estimated a confirmatory factor model to study the validity of the scale and examined the underlying structure. To this end, we created a causal model and used structural equations to evaluate the scale and the effect of technology acceptance and use on omnichannel shoppers' purchase intentions.The study was approved by the Head of Ethics at the Faculty of Business Administration of La Rioja University. All participants provided informed consent.innovativeness3 had a value lower that 0.7 and a t-value lower that 1.96. We thus decided to exclude it to improve the model's convergence, as recommended by Anderson and Gerbing , convergent validity, and discriminant validity. The composite reliability and Cronbach's alpha values were >0.70, and the constructs' convergent validity was also confirmed, with an average variance explained (AVE) >0.50 in all cases. The discriminant validity of the constructs was measured by comparing the square root of the AVE of each construct with the correlations between constructs , H2 (regarding the influence of effort expectancy), and H6 . In contrast, H3 , H4 (regarding the influence of habit), H5 (regarding the influence of hedonic motivation), and H7 (regarding the influence of perceived security) were rejected, as the relationships were not significant.The sign, magnitude, and significance of the path coefficients are shown in Table omnichannel retailing . Our findings show that a consumer's intention to purchase in an omnichannel store is influenced by personal innovativeness, effort expectancy, and performance expectancy. In contrast, contrary to our hypotheses based on the broader previous literature, habit, hedonic motivation, social influence, and perceived security do not affect omnichannel purchase intention.The model was found to predict omnichannel purchase intention (Personal innovativeness is the strongest predictor of purchase intention in the omnichannel context. This factor plays an important role as a direct driver of omnichannel purchase intention. This finding is consistent with those of previous papers (e.g., Herrero and Rodriguez del Bosque, effort expectancy and performance expectancy are significant factors in explaining attitude and purchase intention, with a positive effect on behavioral intention, as has been widely reported in the literature (e.g., Childers et al., Effort expectancy is the second strongest predictor and has a direct positive influence on purchase intention (e.g., Karahanna and Straub, performance expectancy was found to be the third strongest predictor of behavioral intention in an omnichannel environment.Our findings also show that social influence on people's attitude, intentions, and behavior (e.g., Fishbein and Ajzen, social influence was found not to affect purchase intention. This finding contrasts with those reported elsewhere (Kim et al., Although the literature has recognized the influence of normative factors such as habit does not influence omnichannel purchase intention. This could be because customers are not used to using different channels due to the relatively low number of companies that allow customers to use multiple channels simultaneously. In keeping with authors such as Valentini et al. (Contrary to previous studies (e.g., Venkatesh et al., i et al.  and Melei et al. , we belihedonic motivation on purchase intention was found to be low. Previous work in other contexts has found a positive relationship between these variables (e.g.,Van Der Heijden, In our research, the hypothesized influence of perceived security did not influence omnichannel purchase intention. We interpreted these results to mean that the possibility of buying in an omnichannel context offsets the influence of the need for security, an important factor in e-commerce, by offering the option of traditional in-store payment, which nullifies the effect of perceived risk in e-commerce. In this sense, omnichannel stores offer an opportunity to attract more conservative consumers who perceive an increased risk in e-commerce to a more interactive scenario in which retailers can use new technologies to manage customer relationships based on direct contact in the physical store.Finally, contrary to previous findings (e.g., Salisbury et al., Our study contributes to the current literature on omnichannel consumer behavior by adapting the previous UTAUT models to include two new factors in order to determine how the technologies used during the shopping process affect the intention to purchase in an omnichannel context. The results have practical implications for omnichannel retailer managers regarding the best management and marketing strategies for improving a key part of their business, namely, the creation of a holistic shopping experience for their customers (Lemon and Verhoef, Our paper has some limitations. Our data are related to consumer behavior in a particular case: the buying process in the fashion retailer Zara. It would be interesting to replicate this study in another product category or country to compare the results.habit as a moderator variable in purchase intention.Our research also suggests interesting lines of future research, such as identifying omnichannel consumer profiles in order to personalize the customer shopping experience. Likewise, future studies could investigate the new role of technology in the physical store in an omnichannel environment. In addition, the influence of sociodemographic variables, such as age or gender, as moderator variables to complement the current model should be explored. In keeping with Chiu et al. , we thinFinally, fashion companies need to determine which factors matter most to consumers 3.0 when they set out on their shopping journey in order to adapt their strategies to shoppers' motivations. This study has sought to shed light on the new omnichannel phenomenon. Technology is changing the future of retailing. The key will lie in successfully integrating all channels in order to think about them as consumers do and try to offer shoppers an integrated and comprehensive shopping experience.The three authors have equally participated in literature review, data analysis and writing of the paper.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.