When new forensic evidence becomes available after a conviction there is no systematic framework to help lawyers to determine whether it raises sufficient questions about the verdict in order to launch an appeal. This paper presents such a framework driven by a recent case, in which a defendant was convicted primarily on the basis of audio evidence, but where subsequent analysis of the evidence revealed additional sounds that were not considered during the trial. The framework is intended to overcome the gap between what is generally known from scientific analyses and what is hypothesized in a legal setting. It is based on Bayesian networks (BNs) which have the potential to be a structured and understandable way to evaluate the evidence in a specific case context. However, BN methods suffered a setback with regards to the use in court due to the confusing way they have been used in some legal cases in the past. To address this concern, we show the extent to which the reasoning and decisions within the particular case can be made explicit and transparent. The BN approach enables us to clearly define the relevant propositions and evidence, and uses sensitivity analysis to assess the impact of the evidence under different assumptions. The results show that such a framework is suitable to identify information that is currently missing, yet clearly crucial for a valid and complete reasoning process. Furthermore, a method is provided whereby BNs can serve as a guide to not only reason with incomplete evidence in forensic cases, but also identify very specific research questions that should be addressed to extend the evidence base and solve similar issues in the future. Extensive research is being undertaken in various scientific disciplines to extend the evidence base that can help the detection, collection, and analysis of forensic evidence INTERPOL . Such emcase assessment and interpretation (CAI) model was developed in the late nineties by Cook et al.  and defence (Hd) hypotheses in the light of n items of evidence, the posterior probabilities When revising the probabilities for a pair of prosecution  the likelihood ratio on its own is a valid measure of probative value of the evidence  and if the LR < 1, the evidence supports Hd . This is very attractive for forensic scientists since it means they can assess the probative value of the evidence without having to provide any prior probability for hypothesis Hp. However, while computing the LR is simple for a single piece of evidence [the expert only has to provide two likelihoods Providing that the pair of prosecution and defence hypotheses are mutually exclusive and exhaustive  and these ‘local’ likelihood values are provided for the NPTs, the over-all likelihood ratio for any set of evidence with respect to any hypothesis node can be obtained by running the model in BN software . Specifically for evidence where To translate the verbal scales used in the case documentation to numerical probabilities, the translation table presented by Morgan  was usedtornado graph.In order to investigate the evidential value of each item of evidence to the hypothesis of interest a sensitivity analysis was performed. Such an analysis allows one to identify those with the strongest evidential value, by calculating and comparing the probabilities of the target node with and without assumed states for (a combination of) the evidence nodes. For example, by comparing Additionally, the effect when the missing conditional probabilities are actually obtained was assessed. This method was designed to result in a transparent reasoning process which is understandable by legal professionals and jurors, and addresses some of the issues raised by Thompson  which arA baby was injured during an incident on the top floor of a houseBlood from the baby was found on the wall in one of the rooms upstairsOn an audio recording of the emergency telephone call made by the suspect, a scraping sound  can be heard  was of interest because of background noise that could be heard simultaneously at this time The proposition that the suspect was rubbing his face was given as an alternative explanation by the defence for the explanation of sound 1 showed similarities to sound 1A second sound (sound 2) was noted on the emergency recording, which, according to the audio expert, During this second sound, the TV (located downstairs) could be heard simultaneously on the emergency recordingA statement by the police reads that the suspect was frequently rubbing his face in their presenceThe audio evidence played a significant role in the trial. However, the assessment of observing the evidence that would be expected if the suspect did indeed scrape blood off the wall was not supported by any empirical studies or past experiences. During the appeal preparation process, the recorded emergency call was re-analysed by an audio expert on behalf of the defence, and four other sounds were identified on the same recording that, according to the expert, Did the suspect attempt to murder the victim?Did the suspect inflict any injuries on the victim?Did the suspect scrape blood off the wall during the emergency call causing sound 1  to the case can be defined as:Clearly, the formulation of the questions in the case assessment stage will impact the structure of the BN. For example, asking similar”“were the sounds is different from asking:“were the sounds produced by the same activity?”unless a similarity is defined as such. This highlights the importance of precisely defining the meaning of the terms used in the assessment.The ultimate question is whether the suspect attempted to murder the victim—as was the final statement in the trial. The other counts that were presented to the jury were innocence or causing GBH. Factors of relevance (and discriminatory power) to the three counts are the degree of preparation, motive, opportunity, intent, and whether or not the criminal action actually took place. It is argued by Fenton et al.  that becconsistent with the suspect scraping blood. Ideally, of course, these hypotheses should be accompanied by an analysis that discusses the validity and accuracy of the evidence presented. However, as this was not done in the trial, it will therefore not be taken into consideration in this model. Statements about the presence of the other evidence types are defined similarly. Thus, the propositions presented in this case are:The suspect scraped blood off the wall at timethe suspect rubbed his face at timeA sound that is consistent with the suspect scraping blood at timeis observed on the recording, and a sound that is consistent with the suspect scraping blood at timeis not observed on the recording,the suspect rubbed his face at timeThe suspect scraped blood off the wall at time A sound that is consistent with the suspect scraping blood at timeis observed on the recording, and a sound that is consistent with the suspect scraping blood at timeis not observed on the recording,Sound 1 and sound 2 are similar, and sound 1 and sound 2 are not similar.the TV cannot be observed on the recording at timeThe TV can be observed on the recording at time The police observed a frequent rubbing activity by the suspect, and the police did not observe a frequent rubbing activity by the suspect.The evidence presented in the trial to support the scraping/rubbing propositions was that of the sound, which is ‘other activity’ could have been included in the activity nodes, if it were not for the fact that questions such as ‘what is the probability of observing a similarity between a sound caused by scraping and one caused by any other activity’ are not possible to address using empirical data. Because of this, for example, a LR of 1 does not indicate that the evidence does not have any probative value: even though it might reduce the posterior probabilities of the hypotheses by equal amounts, it could increase the posterior probability of the third ‘other’ hypothesis  and defence (rubbing activity) hypotheses are assumed to be mutually exclusive but not exhaustive, since the proposition that it is caused by another activity is not considered  state names will be used to refer to the state of the nodes in the equations to maintain conciseness [e.g. very likely to be present  and therefore assessing the support of evidence of the expert witness statement on the degree of similarity:The probability of observing a similarity between the two sounds given that each of the sounds are caused by a In order to obtain these probabilities, experimental studies should have been performed in which the case situation is simulated and the different sounds resulting compared.The probability of the police observing a rubbing activity and writing this into a statement (states a lot more likely that the television could not be heard TV = tv), given that the suspect was scraping the wall at time t2:Because the television was, according to the case records, positioned in a downstairs room relatively far away from the upstairs bedroom in which the scraping allegedly took place, it is considered to be The full set of  probabilities for the BN model is presented in Fig. A1 is conditional and depends on different factors that need to be assessed. Even though there is scope for disagreement regarding the probabilities and assumptions, it is possible to make inferences from the BN that can aid the interpretations of evidence within the case.It follows from the BN in Fig. does the new appeal evidence change the belief indoes the presence of the new appeal evidence lower the probability ofz discussed in the previous section are different in such a way that x , key evidence is missing to come to any conclusion. Figure y = 0.5, a difference in the z-value changes the LR to such an extent that the evidence supports different hypotheses depending on this value:z < 0.35, LR < 1, indicating that the evidence supports the hypothesis that the suspect was undertaking a normal behaviour, which is beneficial for the defence.For 0 ≤ z < 1.0, LR > 1, indicating that the evidence supports the hypothesis that the suspect was undertaking a ‘suspicious’ behaviour, which is beneficial for the prosecution.For 0.35 < The question that is of interest in a legal setting is: ‘LR < 1, dark points) or the prosecution  depending on the values for the unknowns y and z. This is especially the case for higher values of y.Following this, Fig. prosecutors fallacy). In order to do this, we need to incorporate the prior probabilities of the prosecutor and defence hypotheses, a value which can vary depending on the background information that one assumes to be present x and the (currently) unknown value of y. A point in the graph indicates that for that specific combination of x and y, varying the value of the other unknown, z, can cause a switch in which sides’ hypothesis is most likely based on the evidence presented at the trial. This is especially the case for lower x values (which would favour the defence) and higher y values . Because of this, the defence should be very careful in presenting the new evidence in its favour when insufficient information is given by the expert with regards to the other unknown variables. However, if experimental studies were to show that the two possible activities do produce dissimilar sounds , the expert evidence reduces the posterior probability of the defendant scraping the wall greatly, which was the aim of the defence. Experimental studies are therefore needed to offer the empirical evidence base to establish the missing parameters in a Bayesian network, leaving less room for speculations.As noted before, the LR only provides information about to what extent the evidence supports one of the hypotheses over the other. However, the court is interested in addressing which of the two hypotheses is more likely based on the evidence . The prior probability x of (A1 = a1p) is also set to 0.5 since no background evidence is assumed to be present before the evidence was presented at the trial. Since the defence assumed a low value for z, a value of 0.1 is used. Note that these values are only selected in order to show the effect and interaction of the items of evidence and are not used to show the evidential value.A sensitivity analysis was performed to identify the items of evidence that have the most impact on the hypothesis A1 (whether the activity that caused the first sound was related or unrelated to the crime). Because P(a1p) = 0.5). For each of the other nodes in the network, the bars represent the extent an assumption about their state impacts the belief that the suspect was scraping blood off the wall at time t1. It follows from Fig. The results of the sensitivity analysis are presented in the form of a tornado graph, see Fig. E1 and E2, the evidence now favours the prosecution without considering any of the other evidence: a1p between 0.51 and 0.77. Subsequently, the evidence related to the television and the observation of the police statement are less significant in changing the belief in a1p. However, because the value of a2p is not known, the related items of evidence are dependent where a change in the belief of S influences the state of the television evidence. To further assess this issue, a similar analysis is performed where the evidence of similarity is assumed to be present  or higher (0.84) than its prior (0.5). This sensitivity analysis thus shows that the inclusion or exclusion of items of evidence in the interpretation process can have a great impact on the significance of other items. Without the presence of the television evidence, the evidence on the similarities brought forward by the defence actually increases the probability of the prosecution hypothesis.The subsequent assumption is made that the items of evidence E1 and E2 are observed to draw further inferences. Figure This study has demonstrated how the Bayesian framework of reasoning can be used to explore how items of evidence are related to each other and to the relevant hypotheses, illustrated by a real case. It highlighted the importance of assessing the information and defining the questions and propositions at different levels before creating the BN model. When one makes reasonable and justifiable decisions regarding aspects such as conditional independence, integrity of expert evidence and assumptions that are made in favour of the defence or prosecution, the BN can be a useful tool to provide transparent and workable results regarding the relevance of new items of evidence.The changes in the key posterior probability was shown to be dependent on the different assumptions, ultimately showing that the incomplete defence expert evidence could also work to weaken the defence case. More specifically, the evidence about similarity of the sounds is the most valuable when aiming to address the activity level proposition, followed by the observation of the TV evidence. Because of this, it is important that experimental studies are undertaken in order to define the probabilistic relationships (Morgan et al. This research therefore addresses a critical issue within the forensic sciences. The importance of presenting—in a holistic, transparent and reproducible manner—all the relevant evidence and hypotheses is, we believe, paramount for optimising the use of valuable forensic evidence in court. This approach enables judges and juries to evaluate the weight of not only individual items of evidence in a case but also identify the interaction of different items of evidence within that case to be able to draw conclusions. Such an approach offers a significant step that enables forensic science to address a number of the critiques that have been made in recent years, and to ensure that the value of physical evidence continues to be realised in forensic investigations and the pursuit of justice.


To the Editor: In an article that reviews evidence of a plot to use plague to break the siege of Candia during the Venetian–Ottoman War of the 17th century, Dr. Thalassinou and her colleagues (Danish historian Karl-Erik Frandsen conducted a careful study of the plague outbreak affecting the Baltic area during 1709–1713 and found no evidence to support this allegation (Intentional introduction of disease has been rare (


This re-focus is derived from observations that two gp41 bnAbs exhibited features suggesting immune tolerance mechanisms limited their induction 4E10 and 2F5, HIV-1 Env gp41 bnAbs with adjacent, linear epitopes in the MPER and two of only three bnAbs to have been directly isolated from HIV-1–infected patients between 1993 and 2009, were identified to have traits associated with negative selection, i.e., long HCDR3s and poly/autoreactivity Recently, conserved vertebrate host antigens recognized by 2F5 and 4E10 have been identified: kynureninase and splicing factor 3b subunit-3 (SF3B3), respectively + bnAbs and to what extent it limits bnAbs targeting other Env regions. The recent identification of 10E8, a potent MPER+ bnAb lacking in vitro polyreactivity These studies A key, related issue regarding how tolerizing self-reactivity impairs bnAb induction is when it is acquired or lost in various bnAb lineages. Since KI mice carrying reverted (unmutated ancestor [UA]) 2F5 BCRs undergo profound central deletion , bnAbs like 2F5 likely have self-reactivity encoded in their primary VDJ rearrangement , while others like CH103 and 4E10, whose UA BCRs lack bnAb and self-epitope specificity in vitro , occurs in germinal centers by two linked mechanisms, IgV region somatic hypermutation and affinity-dependent selection. In secondary responses to conventional antigen, somatic mutation levels are normally restricted, because excess mutation decreases affinity and cell survival + bnAb derived from a donor that seroconverted after ∼2.5 years) and its virus targets were molecularly elucidated Studies examining the in vivo evolution of clonal bnAb lineages during chronic HIV-1 infection These studies, and recent findings that most experimentally reverted bnAb UAs lack neutralizing epitope affinity Current HIV-1 vaccination strategies induce antibody mutation profiles (∼4%–5%) similar to autologous neutralizing antibodies in acute HIV infection and most human antibodies produced in 2° responses to infection Although our studies suggest host mimicry by HIV-1 Env gp41 neutralization epitopes limits bnAb induction


Disparities in injury rates between Aboriginal and non-Aboriginal populations in British Columbia (BC) are well established. Information regarding the influence of residence on disparities is scarce. We sought to fill these gaps by examining hospitalization rates for all injuries, unintentional injuries and intentional injuries across 24 years among i) Aboriginal and total populations; ii) populations living in metropolitan and non-metropolitan areas; and iii) Aboriginal populations living on- and off-reserve.We used data spanning 1986 through 2010 from BC’s universal health care insurance plan, linked to vital statistics databases. Aboriginal people were identified by insurance premium group and birth and death record notations, and their residence was determined by postal code. “On-reserve” residence was established by postal code areas associated with an Indian reserve or settlement. Health Service Delivery Areas (HSDAs) were classified as “metropolitan” if they contained a population of at least 100,000 with a density of 400 or more people per square kilometre. We calculated the crude hospitalization incidence rate and the Standardized Relative Risk (SRR) of hospitalization due to injury standardizing by gender, 5-year age group, and HSDA. We assessed cumulative change in SRR over time as the relative change between the first and last years of the observation period.Aboriginal metropolitan populations living off-reserve had the lowest SRR of injury (2.0), but this was 2.3 times greater than the general British Columbia metropolitan population (0.86). For intentional injuries, Aboriginal populations living on-reserve in non-metropolitan areas were at 5.9 times greater risk than the total BC population. In general, the largest injury disparities were evident for Aboriginal non-metropolitan populations living on-reserve (SRR 3.0); 2.5 times greater than the general BC non-metropolitan population (1.2). Time trends indicated decreasing disparities, with Aboriginal non-metropolitan populations experiencing the largest declines in injury rates.Metropolitan/non-metropolitan residence appears to be a more important predictor than on/off-reserve residence for all injuries and unintentional injuries, and the relationship was even more pronounced for intentional injuries. The persistent disparities highlight the need for culturally sensitive and geographically relevant injury prevention approaches. Disparities in injury rates when comparing Aboriginal and non-Aboriginal populations in many countries with indigenous populations are well documented –6. In CaCanada’s Aboriginal population reflects a vast array of cultures, linguistic and geographic circumstances , 10. OveHistorical colonial practices and policies, such as banning Aboriginal traditional practices and removing children from their families for residential school education, aimed to decimate Aboriginal cultural heritage and subjugate Aboriginal populations to White European rule , 12. ColDuran and Duran highlight the psychological effects of colonial legacies: loss of power, despair, and self-hatred . These hThe critical population health approach considers the processes and drivers that influence the social determinants of health and seeks to deconstruct the social, economic and ideological forces that undermine health for given populations; in so doing, promoting social, economic and political forces for emancipation and health promotion , 20. GivWhile it is well established that Aboriginal populations have higher rates of injury than non-Aboriginal populations, these population-level statistics mask considerable variability between different Aboriginal communities; which can illuminate potential paths for prevention. A case in point is Chandler and Lalonde’s analysis of youth suicide rates among First Nations communities in BC, which showed that some bands experienced many times the rate of youth suicides than others –23. TheiOur RISC  research project , was insOur work to date has supported our hypothesis and assumptions. In a previous paper, we reported results indicating vast differences in several social determinants of health across Aboriginal communities, including levels of income, education, housing quality, work participation and conditions, and geographic circumstances . For exaIn this paper, we use a critical population health approach to further explore the influence of residence as a determinant of injuries for Aboriginal populations in BC. Aboriginal populations in BC can live in any of the following places: metropolitan on-reserve, non-metropolitan on-reserve, metropolitan off-reserve and non-metropolitan off-reserve. As outlined in the sections below, each of these residences has different geographic and cultural implications that can potentially influence injuries.per se [Regardless of Aboriginal status, geographic remoteness influences disparities in injury rates among Canadians. Injury-related death rates are up to 79 % higher in rural areas compared to metropolitan areas, and disparities widen with increasing rurality . Behavioper se , 35.We would expect that Canada’s Aboriginal populations would disproportionately experience the injury-related disadvantages associated with rural living because they are more likely to live in rural areas (46.8 %) , than noEffects of colonial traumatisation may also be evident for Aboriginal populations living in rural areas. Place  presenteAn increasing proportion of Aboriginal people are living off-reserve and in urban areas . Among BTjepkema  and PlacSocioeconomic factors are generally worse for on-reserve than off-reserve residents. For example, among BC’s Aboriginal on-reserve population, 19.8 % had a high school certificate and 75.8 % participated in the labour force, compared to 26.2 and 84.9 %, respectively for the off-reserve population . What efWhile socioeconomic indicators may point to improved circumstances for off-reserve residents, the “group density effect” would predict better health for on-reserve populations . This efIn this paper, we sought to examine the influence of residence on injury-related hospitalization rates for all injuries, unintentional and intentional injuries among i) Aboriginal and total populations; ii) populations living in metropolitan and non-metropolitan areas; and iii) Aboriginal populations living on- and off-reserve. We also analyzed injury rate time trends across 24 years of data. In defining metropolitan and non-metropolitan, we adapted the Statistics Canada definition, referring to “large population centres”  as “metropolitan” areas and all others as “non-metropolitan” areas .Disclaimer: all inferences, opinions, and conclusions drawn in this journal manuscript are those of the authors, and do not reflect the opinions or policies of the Data Stewards.The University of British Columbia Behavioural Research Ethics Board reviewed and approved our methods. The Data Stewards representing the BC Ministry of Health Services and the Vital Statistics Agency of BC approved the data access requests. We used existing databases, permanently linked by British Columbia Personal Health Number, maintained by Population Data BC. Population Data BC rendered the client records anonymous before our analysis. Membership in Medical Services Plan Premium Group 21 ; orOne or both parents with Aboriginal status or resident on an Indian Reserve, as indicated on the linked Vital Statistics birth record ; orAboriginal status or resident of a First Nation reserve, as indicated on the linked Vital Statistics death record .We obtained annual snapshots of the consolidated registration and premium billing files of the Medical Services Plan of BC , representing fiscal years 1985-86 through 2010-2011 . We tookWe previously described this method, and discussed the quality of the population registry, and validity and limitations of the Aboriginal identification , 24–26.We classified as “on-reserve” those Aboriginal people residing in a postal code area associated with an Indian reserve or settlement recognized by Statistics Canada and the federal Department of Aboriginal Affairs and Northern Development. We classified all other Aboriginal people as “off-reserve”.There are sixteen Health Service Delivery Areas (HSDAs) in BC . We clasWe tabulated discharge summary records representing hospital separations occurring in BC from January 1, 1986 through March 31, 2010 . We cons2)/(SRR1)) = zero.For the Aboriginal population of BC , and the total population of BC (categorized by metropolitan or non-metropolitan residence), and for unintentional injuries, intentional injuries, and all injuries, we calculated the crude rate of hospitalization due to injury per 10,000 person-years, Standardized Relative Risk (SRR) of hospitalization due to injury , and 95 % confidence intervals of the crude rate and SRR, using the method of indirect standardization . We test2/SRR1) - 1. To facilitate comparisons, we converted relative change over a period of multiple years to an annualized change, using the following formula.Cumulative change in SRR was assessed over time as the relative change between the first and last years of the observation period, i.e., (SRR2)/(SRR1)) Aboriginal = Ln((SRR2)/(SRR1)) BC.We compared the cumulative change (from the first to the last years) among Aboriginal people to the cumulative change over the same period among the total population of BC. We tested the statistical significance of the difference by calculating the probability  that Ln((SRRAs seen in Table Table Table p = 0.0502 (2-sided), and on-reserve metropolitan SRR = 4.22 vs. off-reserve metropolitan SRR = 4.58, p = 0.3472 (2-sided). On the other hand, the differences between metropolitan and non-metropolitan Aboriginal populations, when stratified by on- or off-reserve residence, are statistically significant: on-reserve non-metropolitan SRR = 5.85 vs. on-reserve metropolitan SRR = 4.22, p < 0.0001 (2-sided), and off-reserve non-metropolitan SRR = 5.29 vs. off-reserve metropolitan SRR = 4.58, p = 0.0141 (2-sided).The differences in the category of intentional injuries, between on-reserve and off-reserve Aboriginal populations, when stratified by metropolitan or non-metropolitan residence, are not statistically significant: on-reserve non-metropolitan SRR = 5.85 vs. off-reserve non-metropolitan SRR = 5.29, Table The largest proportion of BC’s Aboriginal populations lived on-reserve in non-metropolitan areas (37.3 %). While previous research indicated that the Canadian off-reserve population was mostly urban , 54, in Our findings comparing all injury-related hospitalizations indicate that (a) non-metropolitan residents are at significantly greater risk than metropolitan residents; (b) Aboriginal populations are at significantly greater risk than total populations; (c) Among Aboriginal populations, on-reserve non-metropolitan populations are at greatest risk, followed by off-reserve non-metropolitan, on-reserve metropolitan, and off-reserve metropolitan. The pattern of Aboriginal populations being at higher risk than the total BC population remained consistent for all injuries, unintentional injuries or intentional injuries, with Aboriginal on-reserve non-metropolitan populations having SRRs 2.5, 2.1 and 5.3 times higher, respectively.Our findings suggest independent and interaction effects of metropolitan/non-metropolitan area and on/off-reserve residence. Living in non-metropolitan areas resulted in a greater SRR of injury hospitalization, regardless of injury intentionality (SRRs = 2.10-5.85) than living in metropolitan areas (SRRs = 1.68-4.58), whether on- or off-reserve. Our findings suggest that metropolitan/non-metropolitan residence appears to be a more important predictor than on/off-reserve residence for all injuries, unintentional injuries and intentional injuries. This relationship was even more pronounced for intentional injuries. Our analysis of differences in SRR of intentional injury stratified by either metropolitan or reserve residence indicated that the difference between metropolitan and non-metropolitan residence remained significant, while on- and off-reserve residence did not.One possibility for the relative importance of metropolitan/non-metropolitan over reserve residence relates to the larger non-metropolitan Aboriginal population in BC, relative to the Aboriginal metropolitan population. Having a greater proportion of Aboriginal populations may dilute the group density effect in on-reserve non-metropolitan areas. In metropolitan areas, the result may be related to the greater availability of ambulatory care options. Lower hospitalization rates have been observed for all causes of diseases in more urban areas, where other options, such as outpatient and home care, are more readily accessible .With respect to intentional injuries and the lack of protective effect of living off-reserve, it is possible that different factors related to on- or off-reserve residence influence intentional compared to unintentional injuries. For example, while opportunities for education, labour force participation, and access to specialist health care tend to be better off-reserve, there may also be more experiences of racism, exclusion and marginalization . These cThe fact that BC’s Aboriginal population – whether dwelling in metropolitan or non-metropolitan areas – experiences significantly more injury-related hospitalizations than the total population, highlights the fact that enduring differences in health equity transcend geographic location. The disparities exist for both unintentional and intentional injuries, but are particularly pronounced for intentional injuries, with SRRs indicating more than four times greater risk. This may suggest that while the colonial legacy manifests across injury types, it is more pronounced for intentional injuries, which, as discussed above, involve a more conscious choice to harm oneself or another person. Further research is needed to untangle the competing effects of socioeconomic status, geographic residence, and Aboriginal status as risk factors for injury.Time trends indicate that injury-related hospitalizations have decreased by at least 50 % for everyone in BC, but that the biggest drop is evident for Aboriginal populations living in non-metropolitan areas (69 %), indicating a decrease in injury disparities. This may result from improvements in injury prevention measures, particularly in non-metropolitan areas. A number of measures to reduce motor vehicle crashes – the primary source of injury disparity between urban and rural areas – have been implemented during the time span covered by this study . Some noIn previous publications, we have outlined the limitations associated with the data and our methods , 24–26. This study outlines significant disparities in injury-related hospitalizations that exist for Aboriginal populations in BC. In addition to being at significantly greater risk than the total population, Aboriginal people face differential risks depending on where they reside, with on-reserve non-metropolitan populations at highest risk. While time trends across 1986 to 2010 that indicate decreasing injury disparities among Aboriginal populations are encouraging, the persistent disparity highlights the need for ongoing efforts to identify culturally sensitive and geographically relevant injury prevention approaches to narrow the gap.The University of British Columbia Behavioural Research Ethics Board reviewed and approved our methods.Not applicable.https://www.popdata.bc.ca/data, contact: Kelly Sanderson, Researcher Liaison Unit Lead, email: kelly.sanderson@popdata.bc.ca; specifications in project file George 11–012) subject to approval by the Data Stewards representing the British Columbia Ministry of Health Services, and the Vital Statistics Agency of British Columbia, for ethical and privacy reasons, because the data pertain to individuals. The data may be accessed and statistically analysed only on Population Data BC’s Secure Research Environment cloud server.The data that we studied –49, 52 a


By using satellite remote sensing data, we analyze the changes of Chl-a concentration, Sea Surface Temperature (SST) and wind speed in the pre- and post-typhoon periods. We also give a preliminary discussion on the different responses of the Chl-a concentration between nearshore and offshore waters. In nearshore/coastal regions where nutrients are generally rich, the Chl-a maximum occurs usually at the surface or at the layer close to the surface. And, in offshore tropical oligotrophic oceans, the subsurface maxima of Chl-a exist usually in the stratified water column. In an offshore area east of Taiwan, the Chl-a concentration rose gradually in about two weeks after the typhoon. However, in a coastal area north of Taiwan high Chl-a concentration decreased sharply before landfall, rebounded quickly to some degree after landfall, and restored gradually to the pre-typhoon level in about two weeks. The Chl-a concentration presented a negative correlation with the wind speed in the nearshore area during the typhoon, which is opposite to the response in the offshore waters. The phenomena may be attributable to onshore advection of low Chl-a water, coastal downwelling and intensified mixing, which together bring pre-typhoon surface Chl-a downward in the coastal area. In the offshore area, the typhoon may trigger increase of Chl-a concentration through uptake of nutrients by typhoon-induced upwelling and entrainment mixing.Typhoons can cause strong disturbance, mixing, and upwelling in the upper layer of the oceans. Rich nutrients from the subsurface layer can be brought to the euphotic layer, which will induce the phytoplankton to breed and grow rapidly. In this paper, we investigate the impact of an intense and fast moving tropical storm, Typhoon Matsa, on phytoplankton chlorophyll-a (Chl- Chl-a concentration is an important index of marine photoautotroph, which is not only the primary producers of marine organic matter, but also the basic link in the marine food structure. It plays an important role in the process of material cycle and energy conversion in the marine ecological system, of relevance to marine atmospheric carbon cycle in the system, environment monitoring, ocean currents , fishery management and so on [a concentration is an important parameter in the study of ocean color and marine ecological environment. Since global warming may bring stronger typhoons [a may be further enhanced.When typhoons pass over the sea, they can effectively promote the marine phytoplankton, hence raising the sea surface Chl-nd so on –7. At prtyphoons , their ia) concentration will also increase. Many studies have shown that typhoons play an important role in the Chl-a concentration increase [The northwest Pacific and the East China Sea are frequently affected by typhoons. The influences of typhoons on the marine environments and climate are becoming a hot topic of research in the world. Each year, over the northwestern Pacific, 30 tropical cyclones on average are generated, roughly 7 of which make the landfall on China. Owing to the global warming and environment deterioration, the intensity of typhoons may increase . The infincrease –11.a concentration and primary productivity and roles of typhoons’ translation speed and forcing time in phytoplankton blooms. By using MODIS-Aqua ocean color remote sensing data, Lin et al. [-a concentration during Typhoon Matsa. We showed and discussed the different responses of sea surface Chl-a concentration between the nearshore and offshore areas.In recent years, researchers studied influences of typhoons on the Chl-n et al.  investign et al.  showed tn et al.  and Chenn et al.  also putn et al. –19. In tSince typhoons have rapidly changing paths and intensities, setting mooring buoys or cruise survey costs enormously. It is hard to access to observational data comprehensively and systematically under the effect of typhoons. In such occasional and risky situations we can neither grasp the response in the upper ocean accurately nor get sufficient space coverage to estimate the phytoplankton blooms quantitatively caused by typhoons with traditional field surveys. So it’s difficult to thoroughly analyze the physical mechanism of the upper ocean response. With the development of technology, people overcome the constraints above by using satellite remote sensing. It provides an efficient method for getting comprehensive observational data in extreme weather events such as typhoons. Now, applying the technology based on satellite remote sensing is an important method to investigate the influence of typhoons on the ocean environment.http://www.remss.com/missions/tmi). The spatial resolution of SST data is 0.25° × 0.25°, which was derived from Remote Sensing Systems sponsored by NASA’s Earth Science Research, Education and Applications Solution Network (REASoN) DISCOVER Project.The cloud-free daily SST images from TRMM Microwave Imager (TMI) onboard the Tropical Rainfall Measuring Mission (TRMM) is adopted. The data is available from December 7, 1997 (http://weather.unisys.com). It records the typhoon maximum sustained wind speed (MSW) and the location of typhoon center for every 6 hours, based on which the translational speed of the typhoon can be calculated.Track data is taken from the US Joint Typhoon Warning Center (JTWC) and Unisys (http://www.remss.com/missions/qscat). The spatial resolution is 0.25° ×0.25°.The microwave scatterometer SeaWinds (QuikScat) data are employed to show the wind field of typhoon. QuikScat daily data is produced by Remote Sensing Systems, sponsored by the NASA Ocean Vector Winds Science Team (-a concentration data are derived from MODIS-Aqua data (http://oceancolor.gsfc.nasa.gov/). We selected the area  affected by Typhoon Matsa for mapping and analysis. Considering the typhoon path as well as the coverage of the Chl-a concentration data, we chose a box covering 26°N~28°N, 120.5°E~122.5°E as a representative of the nearshore area, and another box covering 22.5°N~24.5°N, 124.5°E~126.5°E as the representative of the offshore area  is calculated asThe Ekman pumping velocity  associated with the upwelling-favorable alongshore wind is calculated as [The coastal upwelling velocity , showing the changes between pre- and post-typhoon ; When the typhoon moved away and wind weakened around August 8, the Chl-a concentration restored to 1.17 mg·m-3, an increase of 60.3%. The Chl-a restored roughly back to the pre-typhoon level two weeks after .The time series of 48-h averaged Chl-trations  were als-a concentrations . Then it began to decline gradually, to the pre-typhoon level on August 23.The time series of Chltrations  indicate-a concentration and SST during Typhoon Matsa appear to be closely related to the wind speed in the nearshore box  phenomenon, has frequently been observed in stratified oceans. Therefore Chl-a maximum value generally appears in subsurface layer with relatively rich nutrients in the stratified water columns of offshore deep oceans. The subsurface maxima of chlorophyll [-a concentrations, where the maximum Chl-a layer is near the depth of 100 m. In the present study, the response of the Chl-a concentration to typhoons in the offshore area is consistent with previous research [-a. In view of the lag time of phytoplankton growth for uptake of nutrients  and thus the increase of the subsurface Chl-a concentration, as well as the surface Chl-a decrease during the typhoon’s approach to the coastline. It is likely that this process created a transient SCM in the nearshore area. However, this downwelling process was soon replaced by an upwelling process (−5 m·s-1 on August 5) after landfall, such that the Chl-a in the transient SCM was brought up to the surface, leading to the rapid, partial rebound of the surface Chl-a concentration. In the meantime, the upwelling process also caused the re-suspension of rich nutrients, which led to the eventual restoration of the Chl-a concentration to the pre-typhoon level. Therefore, the pattern of Chl-a in the nearshore area during the typhoon may mainly be regulated by typhoon-induced mixing, onshore advection, and coastal downwelling and upwelling.On the contrary, the Chl studies ,34–36 inu et al.  in Hong  onshore , causing-a to physical disturbances induced by Typhoon Matsa in the East China Sea. We arrived at the following conclusions: (1) SST significantly dropped in both the nearshore and offshore areas after the typhoon passage. (2) In the nearshore area, the Chl-a concentration decreased sharply in a couple of days after the typhoon passage, recovered to some degree soon after, and restored to the pre-typhoon level in about 2 weeks. In the offshore area the Chl-a concentration increased gradually in about 2 weeks after typhoon. (3) In the nearshore area, the rapid responses (decrease) of Chl-a were probably attributable to the direct wind mixing and the coastal downwelling associated with the onshore surface Ekman transport which advects low Chl-a water towards the coast. The coastal downwelling was replaced by upwelling after the typhoon landfall, resulting in a rapid partial restoration of the Chl-a concentration, through the uptake of the sub-surface Chl-a which was likely enhanced by the mixing and downwelling before landfall.Satellite remote sensing data were used to investigate the responses of Chl


BMC Medicine, we explored whether evidence-based medicine can actually be sure that ‘sucrose = sucrose’ in the treatment of depression. This paper, based upon a reductio ad absurdum, addressed an epistemological question using a ‘scientific’ approach, and could be disconcerting as suggested by Cipriani and Geddes’ commentary. However, most papers are based upon a mixture of observations and discussions about sense and meaning. Ultimately, there is nothing more than a story, told with words or numbers. Randomised controlled trials provide information about average patients that do not exist. These results ignores an entire segment of therapeutics that plays a crucial role, namely care. This information is usually set out using a ‘grammar’ that is ambiguous, since statistical tests of hypothesis have raised epistemological questions that are not as yet solved. Moreover, many of these stories remain untold, and unpublished. For these reasons evidence-based medicine is a vehicle for many paradoxes and controversies. Reductio ad absurdum can be useful in precisely this case, to underline how and why the medical literature can sometimes give an impression of absurdity of this sort. Even if the data analysis in our paper was rather rhetorical, we agree that it should comply with the classic standards of reporting and we provide the important extra data that Cipriani and Geddes have requested.In a meta-analysis published in http://www.biomedcentral.com/1741-7015/11/230 and http://www.biomedcentral.com/1741-7015/12/105.Please see related articles:  BMC Medicine[reductio ad absurdum, but basically an essay about science and care with certain epistemological dimensions. We submitted it to stimulate reflection about the validity of scientific knowledge in medicine and we are glad that it has worked, with a very interesting commentary by Cipriani and Geddes on our published article [In our recent paper published in  Medicine, we expl article .reductio ad absurdum have a place in evidence-based medicine?Beyond addressing a complex and controversial issue within the field of antidepressant research, we believed that the form of this unusual paper raised an important issue implicitly suggested by Cipriani and Geddes’ comments: does Cipriani and Geddes are right to point out that while our paper addressed an epistemological question we approached it ‘scientifically’ by conducting a systematic review and meta-analysis. Indeed, this can be considered as a challenge to the comfortable dualism at the basis of modern science: words are seen as being for philosophers and numbers for ‘hard’ scientists. We clearly militate for abandoning such a position, which sterilises the debate, especially in the field of psychiatric research . To sum To deal with the question of variability and randomness, randomised controlled trials (RCT) tell stories about average patients who, unfortunately or hopefully, do not exist in practice. Statistical inferences underpinning RCT conclusions concern expected values of random variables. In more human terms, these inferences involve the comparison of two or three run-of-the-mill patients (average), with blurred profiles (standard deviation). The story told by an RCT focuses on efficacy, sometimes effectiveness, and specifically on the pre-post difference in a very limited aspect of the average patient. This story does not tell much about the individual patient’s story that a clinician is faced with  and ignoP-value. Unfortunately, most clinicians and non-statistician researchers are in the habit of mixing the two approaches, and this creates fuzziness in most conclusions in biomedical research in general, and RCTs in particular. The importance of significance testing in science is surely overstated, with a fallacious tendency to deflect attention from the actual size of an effect [Natural languages are mainly bottom-up constructions and this means that stories have more or less the same meaning for everybody that reads them. This is not true for evidenced-based stories, which rely on a top-down grammar that is substantially misunderstood. Indeed, statistical tests of hypotheses have raised epistemological questions that are not yet solved . Statistn effect ,7 and drMost families have secrets, but the kind and importance vary. When evidence-based stories are told, the storytellers at the top of the paper are not always a good indication of who actually wrote them, since ghost-writing is endemic . Moreove‘Family secrets’ can sometimes cause illnesses and scientific remedies cannot be the cure in the case of Evidence Based Stories. Europe has recently made an important step forward by voting in favour of a law that will require all clinical drug trials in Europe to be registered and their results reported in a public database .Reductio ad absurdum can be precisely useful in this case, to underline how and why medical literature can give an impression of absurdity of this sort. In evidence-based medicine, this manner of reasoning is usually confined to Christmas issues in general journals. This curious ritual probably has an outlet function, authorising a return of repressed material from evidence-based medicine in a socially acceptable manner.For these reasons, and despite a grammar based upon probability, evidence-based medicine boasts more than its fair share of improbable stories. All the ingredients listed above are present in antidepressant literature, resulting in many paradoxes and controversies, based upon different ways of telling the same stories ,14. ReduBMC Medicine editors and reviewers accepted our improbable story in which the data analysis was in fact rather rhetorical . We agree that it should nonetheless comply with the classic standards of story-telling [We are glad that the -telling  and we aRCT: Randomised controlled trials.The authors declare that they have no competing interests.NF is a psychiatrist who works as a chief resident at the Department of Psychiatry of the University of Rennes. His main research focuses on methodological peculiarities of the evaluation of treatments in psychiatry. FB is a psychiatrist and professor in biostatistics at the Université Paris-Sud. He works on subjective measurements and more generally in innovative methods that can be used to grasp the patient’s perspective.DATABASE.Click here for fileFORESTPLOT.Click here for file


There is growing recognition that “context” can and does modify the effects of implementation interventions aimed at increasing healthcare professionals’ use of research evidence in clinical practice. However, conceptual clarity about what exactly comprises “context” is lacking. The purpose of this research program is to develop, refine, and validate a framework that identifies the key domains of context (and their features) that can facilitate or hinder (1) healthcare professionals’ use of evidence in clinical practice and (2) the effectiveness of implementation interventions.A multi-phased investigation of context using mixed methods will be conducted. The first phase is a concept analysis of context using the Walker and Avant method to distinguish between the defining and irrelevant attributes of context. This phase will result in a preliminary framework for context that identifies its important domains and their features according to the published literature. The second phase is a secondary analysis of qualitative data from 13 studies of interviews with 312 healthcare professionals on the perceived barriers and enablers to their application of research evidence in clinical practice. These data will be analyzed inductively using constant comparative analysis. For the third phase, we will conduct semi-structured interviews with key health system stakeholders and change agents to elicit their knowledge and beliefs about the contextual features that influence the effectiveness of implementation interventions and healthcare professionals’ use of evidence in clinical practice. Results from all three phases will be synthesized using a triangulation protocol to refine the context framework drawn from the concept analysis. The framework will then be assessed for content validity using an iterative Delphi approach with international experts .This research program will result in a framework that identifies the domains of context and their features that can facilitate or hinder: (1) healthcare professionals’ use of evidence in clinical practice and (2) the effectiveness of implementation interventions. The framework will increase the conceptual clarity of the term “context” for advancing implementation science, improving healthcare professionals’ use of evidence in clinical practice, and providing greater understanding of what interventions are likely to be effective in which contexts. Healthcare professionals’ use of research evidence in clinical practice is critical to improving population health and achieving a high-performing health system. Yet, one of the most consistent findings in health services and clinical research is that healthcare professionals’ use of evidence is suboptimal despite increased awareness of and accessibility to research evidence –5. Our uWhile context is broadly known as the physical and social environment, the term is used differently by different authors. More specifically, there is little agreement about what domains, measures, and features of context are important to healthcare professionals’ use of evidence. For example, Øvretveit  defines Context will vary by setting; however, a core set of domains of context that are important to all or most healthcare professionals’ use of evidence in clinical practice is likely to exist. While each domain may be more or less important in different settings, each should, at minimum, be assessed prior to designing and delivering implementation interventions.Keystone, conducted in Michigan, USA) and then explored what happened when a program it inspired (Matching Michigan) was launched. They reported that application of the program’s technical practices were generally very good, but implementation of the broader set of factors shown to be relevant to success in the original program was highly variable and depended on the national, local, and internal context [Empirical evidence supporting the central role of context to implementation interventions has emerged in studies where intervention effectiveness varied by context. For example, Hogg et al. , 24 cond context . These eDiffusion of Innovations [Promoting Action on Research in Health Services (PARiHS) framework was developed to explain healthcare professionals’ use of evidence in clinical practice. It is hypothesized to be a function of (i) the sources of evidence used to support practice change, (ii) the context  where practice change occurs, and (iii) methods used to facilitate practice change [Knowledge to Action Cycle [Consolidated Framework for Implementation Research (CFIR), which recognizes the multiple levels at which contextual influences on behavior change operate and allows for interaction between contextual factors insofar as they influence clinical practice. The framework includes 8 concepts related to the intervention itself, 4 related to the outer context (such as the patient and resources), 12 related to the inner setting or context (such as culture and leadership), 5 related to the individual, and 8 related to processes (such as planning and reflection). This framework reflects the organizational and policy literature, where context is examined from the perspective of levels. In the field of health psychology, there is the Theoretical Domains Framework [While several implementation frameworks acknowledge the importance of context, authors provide little detail on what they consider to be the key domains of context. Rogers’ ovations  is the movations . It descovations . The Proe change , 30. Theon Cycle  also higon Cycle  describeramework , 34. Thiramework . The orgFirst, while several implementation frameworks include context, no one framework is sufficiently inclusive or comprehensive about what comprises context. Secondly, existing frameworks are often inconsistent with one another regarding how they define context and what they consider to be the important domains of context. As a result, there is little direction on which elements of context need to be assessed prior to designing an implementation intervention to improve healthcare professionals’ use of evidence in clinical practice. Thirdly, knowledge users  have not always been engaged in developing the existing frameworks, meaning their knowledge on what domains of context are important to evidence use by healthcare professionals and to the success of implementation interventions is lacking in these frameworks. This may limit knowledge users’ acceptance and thus use of the frameworks to assess context to inform their implementation efforts. Fourthly, the existing frameworks were not subject to international content validation with expert-user groups, which is critical to ensuring that the framework is acceptable and useful to its users [Despite the abundance of frameworks that identify context as an influence on implementation, several unanswered questions about context remain. ts users .Increasing clarity about the concept of context will lay the basis for increasing understanding of context for advancing implementation science, designing and delivering effective implementation interventions, and reducing variation in the effectiveness of these interventions. Because of the different levels and multiple features of context, which may indicate different domains of context, we believe it is important to construct a framework that describes context both fully and precisely, supporting development of the science of implementation research. Therefore, the purpose of the research program described in this manuscript is to develop, refine, and validate a comprehensive framework of context that identifies the domains of context (and their features) that can facilitate or hinder (1) healthcare professionals’ use of evidence in clinical practice and (2) the effectiveness of implementation interventions.This project is a multi-phased investigation of context using mixed methods.To conduct a concept analysis of context as it is described in the international literature in order to develop a preliminary framework of domains of context (and their features) important to healthcare professionals’ use of evidence in clinical practice To conduct a secondary analysis of qualitative data collected from healthcare professionals internationally on the perceived contextual barriers and enablers to their use of evidence in clinical practice To conduct interviews with a variety of international health system stakeholders and change agents to elicit their knowledge and beliefs about contextual features that influence the effectiveness of implementation interventions and healthcare professionals’ use of evidence in clinical practice To synthesize data from the three context studies in order to refine the framework of context drawn from the concept analysis—Context study 1 To assess the resulting context framework for content validity through an iterative process involving expert researchers and health system stakeholders and change agents .The specific objectives of this project are:A protocol describing our methods for the concept analysis is published elsewhere . We are A secondary analysis of qualitative (semi-structured interview) data investigating healthcare professionals’ perceived barriers and enablers to their use of evidence in clinical practice will be conducted. While secondary analysis of quantitative  data is increasingly undertaken, data sharing among qualitative researchers is less common. According to Cotri and Thompson , 40 and The sample consists of 13 individual datasets including interviews from 312 healthcare professionals in four countries: Canada, USA, UK, and Australia. A variety of healthcare professionals are included, for example, different specialties of physicians , and nurses , trainee doctors (residents), chiropractors, and organ donor coordinators. A variety of clinical settings are also included: different types of hospital units  and primary care settings . The 13 datasets are summarized in Table Data analysis will be managed using NVIVO software . All traThe sample is health system stakeholders and change agents who are responsible for the design and implementation of implementation interventions, programs, and change processes that are focused on improving healthcare professionals’ use of evidence in clinical practice. Participants will be purposefully selected from the four countries represented by our team: Canada, USA, England, and Australia. These countries have different health systems; by sampling across these systems, we will capture variation in macro contextual factors. We will purposefully sample from each country to ensure that we interview a variety of participants, for example within (1) public health systems (where the government predominantly covers costs), (2) private health systems , and (3) managed care health system . Because there will also be different health systems within public, private, and managed care programs by country, we anticipate recruiting 12–20 individuals across settings  working in each of (1) public, (2) private, and (3) managed care systems, for a total of 36–60 interviews for this phase of our research program.Semi-structured key informant interviews will be conducted using an interview guide designed to elicit participants’ knowledge and beliefs about context . Interviews are expected to last 45 min, be conducted by telephone, and will be digitally recorded (with consent). To monitor the progress of the interviews, permit follow-up of issues that may emerge from the data, and allow us to assess whether we have reached data saturation, interviewing, transcription, and analysis will proceed concurrently. The digital recordings will be transcribed verbatim and verified by the interviewer prior to analysis. Inductive data analysis using constant comparative analysis, as described under The findings from the three context studies described above  will be triangulated in order to refine and increase confidence about the comprehensiveness of the preliminary context framework derived from the concept analysis. We will follow a 6-step triangulation process as outlined by Farmer and colleagues  and as sThe final phase of our research program is to assess the content validity of the refined context framework resulting from the data triangulation phase. A modified Delphi approach –51 will n = 65 can be treated as normally distributed, allowing the use of large sample estimators with more robust properties in Delphi analyses. Therefore, 70 participants will be recruited. Assuming a 50 % response rate [Participants will be selected from the international research and healthcare delivery community and will include (1) researchers from a variety of disciplines  that study context and implementation in healthcare and (2) health system stakeholders and change agents who are responsible for the design and delivery of interventions, programs, and change processes focused on increasing evidence-use by healthcare professionals in clinical practice. There is a broad range of estimates of suitable sizes for a Delphi panel. Lumley et al. , howevernse rate , 140 expRound 1. Participants will be provided with (1) a description of the process used to develop the context framework, (2) a data triangulation table that summarizes the framework domains (and their features) of context with supporting evidence from the three context studies conducted, and (3) a questionnaire that asks the experts to rate their strength of agreement  from Round 1 will be fed back by email to the experts who will be asked to confirm or revise their initial views, Round 3. Round 2 will be repeated if needed. A maximum of three rounds will be conducted to limit participant burden.Participants in the Delphi process will complete 2–3 email questionnaires estimated to take 20–30 min to complete nt scale , 60) witAll participants will be treated and analyzed as a single group of experts. The initial ratings of agreement from Round 1 will be summarized as frequency distributions together with measures of dispersion (interquartile ranges) and central tendency . In line with previous Delphi studies, participants will be considered as in “disagreement” if 30 % or more of the ratings are in the lower third (ratings 1–3), and 30 % or more of the ratings are in the upper third (ratings 7–9) . Contextshared understanding of context that is needed to advance the science of implementation. The framework will be useful to both researchers and knowledge users . Researchers and knowledge users may be able to use the framework to guide a priori assessments of context (to assist in the design and delivery of their implementation interventions) as well as a posteriori assessments of context . Researchers and knowledge users may also be able to use the framework to pragmatically guide their implementation efforts by identifying important features of context that are important to consider when choosing, designing, and delivering implementation interventions, and to help assess the transferability of effective implementation interventions from other contexts to theirs by identifying contextual features that may influence effective implementation.This paper presents the protocol of a multi-phased research program that takes up the challenge to develop, refine, and validate a comprehensive framework of context that identifies the key domains (and their features) of context that facilitate and hinder (1) healthcare professionals’ use of evidence in clinical practice and (2) the effectiveness of implementation interventions. The framework will represent a


The quality medical laboratory services play a vital role in healthcare systems. Iran has set national standards based on the international standard ISO15189. These standards came into force in September 2007. Given the important role of both laboratories professional and assessors in the standardization, this study aims to compare and analyze medical laboratory directors’ and assessors’ opinions about this process, its challenges and relevant solutions.This qualitative study was conducted on two populations in 2013. The first survey population consisted of 150 assessors. The second group consisted of directors working in medical laboratory settings. From all universities of medical sciences, 258 medical laboratories were randomly selected. Data were gathered using two open-ended questionnaires and analyzed using the thematic analysis.Challenges and relevant solutions regarding the standardization and standards, the assessment process and assessor, laboratories, external entities and contextual factors across laboratories directors and assessors were derived and compared. Both groups had a positive attitude towards the standardization process. However, they expressed some concerns regarding the process and accordingly proposed solutions to overcome the challenges.This study provides insights into the challenges and solutions of the standardization from two professional groups’ viewpoint. These two factors are closely related and should be considered when implementing standards since a positive perception of them increases the likelihood of successful standardization. Similarities and divergences regarding challenges and solutions of the standardization, in turn, can provide insights into how this process can be improved and deserve policy makers’ attention to continue the progress. Medical laboratory services play a vital role in healthcare systems;  high-quaThe standardization process involves participation from frontline staff to senior management and their perceptions on this process are hence important. On the other hand, the core of the accreditation process is assessors recruited to conduct quality assessments using relevant standards. Their role in facilitating continuous quality improvement is also increasingly recognized . So, undTo this end, the perspectives of both groups were examined to uncover similarities and divergences in the standardization within and across medical laboratory directors and assessors. This research is the first to compare and analyze the opinions of medical laboratory directors and assessors about the standardization process, its challenges and relevant solutions to use standards in Iran. This in turn can provide insights into how this process can be improved.This qualitative study was conducted on two populations in 2013. The first survey population consisted of all 150 assessors employed by the GDLA in each university of medical sciences who were selected from 330 assessors using the RHL database. The second group consisted of directors working in medical laboratory settings. Using the RHL database, 258 medical laboratories from all universities of medical sciences were randomly selected. The laboratories were from public/private sectors and hospital-based/outpatient laboratories.Data were gathered using two open-ended questionnaires derived from the review of literature and the experts’ opinion. To check the reliability and validity of the questionnaires, they were pilot tested by four medical laboratory directors and four assessors and minor changes were made accordingly. The questions were about the participants’ perceptions of challenges and solutions regarding the national standardization scheme, the assessment process and assessors, laboratories, external entities and contextual factors. The questionnaires were sent via mail along with an official invitation letter signed by the RHL director. The information sheet and consent form were provided. The ethics approval was obtained by Tehran University of Medical Sciences research ethics committee. The qualitative data were analyzed using the thematic analysis. The member check strategy was used and comments were incorporated in the final analysis. It helped to ensure that the findings were congruent with the participants’ perceptions and opinions.Of the 150 questionnaires sent to assessors, 51 completed questionnaires were returned. The assessors working in GDLA completed the questionnaire. They had an average laboratory job experience of 15 years (range 15-22) and had worked as assessors for 4 years (range 2-6). In regard with educational certifications, most respondents (80%) were medical laboratory scientists. The medical laboratory directors had a doctoral degree in medical laboratory science, followed by clinical pathology (30%) and other laboratory specialties. The mean years of job experience was 20.8. Out of 258 questionnaires, 100 completed ones were received. There were 62 private outpatient laboratories, 20 public and 18 private hospital based laboratories in the study.Data collected from the questionnaires were coded and accordingly and categorized into five themes regarding challenges and proposed solutions from the point of view of both assessors and laboratories directors were developed. The themes included attitudes towards the standardization and standards, the assessment process and assessor, laboratories, external entities and contextual factors. Similarities and divergences regarding challenges and solutions of the standardization across medical laboratory directors and assessors were then explored. These findings have been provided in Both assessors and laboratories’ directors had a positive attitude towards the standardization process and acknowledged it as a tool for quality improvement. However, they expressed some concerns regarding the standardization process and accordingly proposed a range of solutions to overcome the challenges. Items considered by assessors as major challenges to the standardization and standards included ‘overly bureaucratic’, ‘time consuming’, ‘inefficient’, ‘costly’, and ‘increased workloads and stress for laboratory staffs’.Although the laboratories’ directors had similar concerns regarding problematic items, they ranked these items differently. These findings are similar to those of a study, conducted by Gough and Reynolds in the UK, on clinical pathology accreditation . The labIn the meantime, several key factors that seemed to make the standardization program operable were identified. The assessors expressed needs for ‘harmonization of practices among laboratories’, ‘revising the standards and related guidelines’, ‘adopting a staged and continuous approach for standardization due to the wide heterogeneity in the laboratories’, ‘recognizing different levels of quality improvement among the laboratories and formulating different operational plans according to laboratories’ resources’.Interestingly, similar solutions regarding the standardization program and it’s standards were explicitly considered by the laboratories’ directors including ‘introducing strategies to raise better understanding of the standardization process’, ‘adopting a stepwise approach’ and a slower and more gradual way of implementation’, ‘revising and updating the standards, their related checklists and the technical guidelines based on the international standards considering the country context and situation’ and ‘learning from experiences of the previous assessment runs’.Adopting a stepwise approach to gradually overcome the challenges was also suggested in a study conducted in Africa  and such stepwise models have already been implemented successfully in Thailand, Argentina and Kenya . FurtherThe second set of aspects considered problematic was related to the assessment process and assessors.The assessors mentioned some challenges regarding the assessment process. ‘Shortage of assessors, assessors’ dissatisfaction’ and ‘the lack of incentives  for the assessors’, ‘difficulties in the standards’ interpretation by assessors’ and ‘inadequate assessor training’ were important perceived challenges. The issue of the staff shortage was also mentioned in studies conducted in Pakistan and Kenya ,. SimilaAssessors mentioned that the assessment of hospital laboratories had been more complex. The multidisciplinary nature of hospital performance, different shifts of work, the diversity in laboratory tests and emergency laboratory tests were issues that make the compliance with standards more difficult compared with outpatient laboratories.Differences in assessing public and private laboratories due to differences in management, financing and complying with standards were also considered as challenges by the assessors. While the license of private laboratories is renewed based on the accreditation results, such a process is not necessarily applied to public laboratories. So the lack of motivation plays a key role in making the assessment process problematic in public sector resulting in the low acceptance due to the lack of compulsory licensing. In two studies conducted in Ghana and Jordon, the issue of mandating laboratories to be licensed has been also pointed .Factors considered by laboratories directors as major challenges of the assessment process and assessor included ‘lack of a shared understanding of the assessment concepts and purposes among the assessors’, the low number of experienced assessors’, ‘inadequate time devoted for each assessment’, ‘long gap between two consecutive assessments’, ‘lack of providing feedback or delayed feedback to the laboratories’, and ‘assessors’ difficulties in communicating with laboratories’, ‘over strict assessments’, ‘inconsistent assessment results by different assessors’, and ‘unfair assessments’.The assessors believed that the reason behind the inadequate number of assessors and their dissatisfaction is mainly the lack of a formal incentive system. Also, another challenge for the assessors was the differences in assessing public/private and outpatient/hospital laboratories. Differences in assessing public and private laboratories due to different managerial structure and financing resources were also noted in a study conducted in Iran . ConversThe assessors mentioned main solutions that help to handle the challenges of the assessment process and assessors. The proposed solutions included ‘clearly defined assessor selection criteria ’, ‘the evaluation of assessment process and assessors based on required professional  and personal attributes’, training  to ensure the sound understanding of the standards and assessment techniques by the assessors and more number of assessors to increase both frequency of assessment and the hours spent by the assessors in the laboratories. Also it has been suggested that assessors’ motivation and commitment be increased and evaluated by both accreditation body and laboratory professionals. So the accreditation body should have data regarding the assessors’ requirements including training, competence and their performance in actual assessment. Finally, more interactions between the assessors and accreditation body, other assessors and laboratory professionals and providing financial rewards and professional recognition for assessors were suggested.Items proposed by laboratories’ directors as possible solutions for the challenges related to the assessment process and assessors included ‘building an assessment culture and clarifying its concept’, ‘following a well-defined plan for assessments’, ‘devoting more time to the assessment process’, ‘conducting assessments in several phases’, ‘providing timely and fair feedback to the laboratories’ and ‘creating a network among the assessors that may facilitate more coordinated and integrated assessment functions’. Likewise, ‘additional recruitments of competent assessors in terms of knowledge, experience and skills’ were proposed. Ultimately, ‘having fixed members of the assessment team for a specific period of time to assure a more consistent approach to assessment’ was also suggested.The assessors’ solutions mainly focused on the assessor selection criteria and appraisal as well as training issues and establishing a reward system which were consistent with findings of other studies (Assessors considered the following items to be major challenges faced by laboratories: ‘the lack of motivation among laboratory professionals’, ‘few laboratories’ involvement in the standardization’, ‘inadequate information about the quality standards among the laboratories’, ‘lack of support from laboratory senior management’ and ‘the weak quality culture’.‘Financial and human resources problems in the laboratories’ were one of the most frequently mentioned problematic factors by laboratories directors, followed by ‘low familiarity with the concepts of the standardization and quality improvement among laboratories’, ‘inertia and reluctance to change’, ‘more pressure on the private laboratories than public owned laboratories’. They also pointed ‘high workload, the inadequate number of laboratory personnel and ‘the high rate of personnel turn over’.The same point of view was held by the assessors and laboratories’ directors regarding the challenges related to laboratories such as laboratories’ low involvement and motivation for the standardization, lack of related information, support and commitment from managers. Pongpiul et al. found similar findings in Thailand .The assessors explained that the most important factors contributing to overcome challenges related to laboratories were ‘training of laboratory staff in understanding the importance of quality concept and issues’, ‘building a culture of quality in laboratories’ and ‘the harmonization among laboratories’.‘More commitment and involvement from laboratory directors regarding the quality improvement and standardization’, ‘the development of a motivation system to enhance the engagement of laboratories’ staff’, ‘training the staff or directors particularly in the domains of documentation’, ‘better communication with other laboratories to exchange experience’, ‘establishing an internal audit system in laboratories to identify the nonconformities’ and ‘participating in the external quality control program’ were solutions proposed by the laboratories’ directors to handle the challenges related to laboratories. The issues of the top managers’ commitment and rewarding systems to motivate laboratories were also suggested in studies conducted in the African Region and Thailand, respectively (Guy-Michel et al., 2010; Items considered by the assessors as problematic issues related to the entities included ‘limited authorities of the GDLA’, ‘low involvement of professional association in the standardization’ and ‘low executive authority of the GDLA’.The laboratories’ directors mentioned challenges regarding the external entities including ‘discrimination against private laboratories by the entities responsible for the accreditation’, ‘the lack of an executive authority, unwillingness and unclear role of professional associations in the accreditation’.Solutions suggested by the assessors regarding the external entities included ‘more involvement of professional associations in accreditation process including composition and revision of standards and guidelines’, ‘setting criteria for assessor selection, evaluation of assessment process, and training’. Also, ‘providing educational courses on quality improvement by universities of medical sciences in order to train competent assessors and laboratories staff’ and ‘adding the principles of quality management system to the academic curriculum of laboratory sciences’ were suggested by the assessors.Laboratories’ directors suggested that professional associations should play a more critical role in the standardization process. Solutions proposed by laboratories’ directors regarding external entities were as follows: ‘the development of incentive mechanisms by the RHL to encourage the accredited laboratories and support them technically or even financially’, ‘the establishment of a coalition and an effective communication among the professional associations and their convergence to make more unified and integrated roles’, ‘more participation of the professional associations in training and empowering the laboratories’ staff and assessors’, revising standards and checklists, ‘the delegation of the assessment process to professional associations’, ‘providing technical assistance to laboratories’, and helping to build a culture of quality’. Also, the laboratories directors suggested that ‘the professional associations play a more eminent role in setting the national laboratory tariff, the quality control of apparatus, and equipment and consumable kits and their pricing’. Their role in ‘the external quality control and calibration’ was also emphasized.With regard to the external entities, both groups expressed concern regarding low involvement of the professional associations and agreed on the necessity of higher involvement of such associations in the standardization process, in general and in training, in particular. Meanwhile, the laboratories’ directors had keen interest in the delegation of the assessment process to professional associations. The benefits of the participation of professional associations in selecting assessors and developing standards and guidelines were also discussed in studies conducted in European Union countries .The assessors agreed that certain issues related to contextual factors were problematic. ‘Low laboratory tariff levels in Iran’, ‘inadequate policy-level support for accreditation’, ‘financial problems, high inflation rate and increased price of laboratory equipment ’ were the most important examples. ‘Financial and economic issues’, ‘lack of timely reimbursement to laboratories by the insurance organizations’, ‘high price of proper kits and equipment’, ‘costs of maintenance services and the space and facilities needed to comply with the requirements of the standards’ were the contextual issues mentioned by the laboratories’ directorsThe following solutions were proposed by the assessors regarding contextual issues: ‘policy-level support for laboratory accreditation system’ and ‘reasonable increase of laboratory tariff levels’.The laboratories’ directors proposed suggestions regarding contextual related issues such as ‘setting reasonable laboratory tariffs’, ‘providing financial aid for the quality improvement program’ and ‘allocating more budgets to medical laboratories’.The contextual related challenges of standardization from both groups’ viewpoints appear to be more similar, including low laboratory tariff levels, financial problems and inadequate policy-level support for accreditation. Solutions proposed by both groups also mainly focused on the reasonable increase of laboratory tariff levels and the policy-level support of both standardization process and laboratories. The necessity of policy-level support for laboratory accreditation was also highlighted in studies conducted in Serbia and Thailand . Also, iThis study provides insights into the attitudes towards the standardization and standards, the assessment process and assessor, laboratories, external entities and contextual factors across two professional groups. It also highlights two perceived challenges and solutions to implement national standards. These two factors are closely related and should be considered when implementing standards since a positive perception of them increases the likelihood of successful standardization. Similarities and divergences regarding challenges and solutions of the standardization within and across medical laboratory directors and assessors, in turn, can provide insights into how this process can be improved. This study may be a useful step to identify current gaps and suggest required interventions. The suggestions introduced in this study deserve policy makers’ attention at both national and local level to continue the progress.


Paediatric rheumatic diseases (PRD) form a group of (rare) diseases that can lead to significant morbidity. Evidence-based guidelines are sparse and treatment regimens differ throughout Europe. In 2012, a European initiative called SHARE (Single Hub and Access point for pediatric Rheumatology in Europe) was granted by the European Agency for Health and Consumers (project number 2011 1202) to optimize and disseminate diagnostic and management regimens in Europe for children with PRD.Workpackage 5 (WP5) aims to develop best practices of diagnosis and treatment for PRD.rd independent expert confirmed the validity and LOE. Papers and scores were used to develop recommendations that were evaluated by all experts via an online survey as a 1st step. Those with < 80% agreement in the survey were reformulated. Finally, recommendations were discussed at a consensus meeting with all experts present, using the nominal group technique [Evidence based recommendations were developed using the European League Against Rheumatism (EULAR) standard operating procedure : Expert echnique . RecommeTable st consensus meeting and will serve as input for the ultimate goal: development of best practices for care and management of PRD throughout Europe. These best practices will be finalized in a 2nd consensus meeting in March 2015 and presented to all stakeholders including paediatric rheumatology units throughout Europe, patient/parent organisations and health authorities.Based upon standardised literature searches, WP5 of SHARE developed evidence based recommendations for diagnosis and treatment of PRD. These recommendations were discussed and agreed upon in a 1S. Vastert Consultant for: consultancy fees < 1000 euro in 2012 from Novartis, P. Dolezalova: None declared., B. Feldman: None declared, A. Ravelli: None declared, N. Wulffraat Grant / Research Support from: Abbvie, Roche, GSK, Consultant for: Novartis, Genzyme, Pfizer, Roche.