Drowning is a heavy burden on the health systems of many countries, including Pakistan. To date, no effective large-scale surveillance has been in place to estimate rates of drowning and near-drowning in Pakistan. The Pakistan National Emergency Department Surveillance (Pak-NEDS) study aimed to fill this gap.Patients who presented with a complaint of "near-drowning" were analyzed to explore patterns of true near-drowning  and intentional injuries that led to the "near-drowning" complaint. Bivariate analysis was done to establish patterns among patients treated in emergency departments, including socio-demographic information, injury-related information, accompanying injuries, and emergency department resource utilization.A total of 133 patients  with "near-drowning" as presenting complaints were recorded by the Pak-NEDS system. True near-drowning (50.0%) and intentional injuries that led to "near-drowning" complaints (50.0%) differed in nature of injuries. The highest proportion of true near-drowning incidents occurred among patients aged between 25-44 years (47.5%), and among males (77.5%). True near-drowning patients usually had other accompanying complaints, such as lower limb injury (40.0%). Very few patients were transported by ambulance (5.0%), and triage was done for 15% of patients. Eleven (27.5%) true near-drowning patients received cardiopulmonary resuscitation.There was major under-reporting of drowning and near-drowning cases in the surveillance study. The etiology of near-drowning cases should be further studied. Patients who experienced non-fatal drownings were more commonly sent for medical care due to other accompanying conditions, rather than near-drowning event itself. There is also need for recognizing true near-drowning incidents. The results of this study provide information on data source selection, site location, emergency care standardization, and multi-sector collaboration for future drowning prevention studies. Injuries are a large, yet often neglected, burden on health systems around the world . The majDrowning is defined by the World Health Organization (WHO) as "the process of experiencing respiratory impairment from submersion/immersion in liquid" . Based oPakistan is the sixth most populous country in the world with a total population of 184 million . It alsoTo date, no large-scale systematic data on drowning and near-drowning have been collected in low-resource environments, including Pakistan . All estThe Pak-NEDS study is an active pilot surveillance study that was conducted between November 2010 and March 2011 in seven urban tertiary care centers situated in five major Pakistani cities of five provinces. The seven study sites are in: 1) Sindh province - Aga Khan University and Jinnah Post-graduate Medical Center in Karachi; 2) Balochistan province - Sandeman Provincial Hospital in Quetta; 3) Punjab province - Benazir Bhutto Hospital in Rawalpindi, and Mayo Hospital in Lahore; 4) Islamabad Federal Capital Area - Shifa International Hospital in Islamabad; and 5) Khyber Pakhtunkhwa - Lady Reading Hospital in Peshawar. Figure Aga Khan University (AKU) served as the main coordinating center for the Pak-NEDS study. Ethical approval for this study was secured from a research ethics committee in each participating hospital, the AKU Ethical Review Committee and Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health in the United States.The Pak-NEDS tool was based on the Centers for Disease Control and Prevention, USA ambulatory care survey tool and previous work undertaken by the investigators ,22. The ® v.12  [All patients  who presented at the participating EDs were registered in the surveillance system. The study aims to establish a standardized active surveillance system across seven sites, therefore no exclusion criteria were employed. Over the four-month data collection period, trained data collectors were responsible for collecting data 24 hours a day, seven days a week in three shifts. The main sources of data were interviews with patients or their next of kin, and ED records. Data collection did not continue beyond the EDs; rather it ended with any actions taken to move the patients out of ED . Data were entered and cleaned by the designated data entry team at AKU using EpiInfo™ v.3.3.2  . The anaas, USA) .In the current article, patients with the presenting complaint of "near-drowning" were collectively analyzed. A distinction was made between true near-drowning patients and intentional injury patients with "near-drowning" complaint: true near-drowning patients were those who incurred unintentional near-drowning incidents, whereas the rest were patients who were suicidal or assaulted, but presented to EDs with "near-drowning" complaint. Descriptive analyses were conducted to explore socio-demographic patterns for all patients with "near-drowning" presenting complaints, first collectively and then based on intention. In addition, concomitant injuries and other health conditions were explored to examine hidden reasons for patients to seek care at EDs. Injury-related information and healthcare resource utilization information were also analyzed. For questions allowing multiple responses, results were presented as a summary of outcomes (noted as "Sum" in tables). For instance, there were ten possible dispositions for ED patients: left without being seen, follow-up planned, return if required, referred to other hospital, referred to outside physician, detained for observation, admitted to ward, admitted to intensive care unit, coronary care unit or high dependency unit (ICU/CCU/HDU), expired, or left against medical advice (LAMA). Each patient can have several combinations of the dispositions, such as "detained for observation" combined with "admitted to ward." Although the combination of outcomes are intuitive, they do not directly provide information on different kinds of disposition. Therefore aggregated results were presented as "summary" information in tables. This information represents a proportion of each disposition in relation to one another. In this example, "disposition" was presented as either "discharged"  or "admitted" .Among Pak-NEDS injury patients, 133 patients  presented with near-drowning events. Among these 133 patients, intention of injury was recorded for 80, and about half suffered from the injury unintentionally . These patients were identified as true near-drowning patients.  among patients who were nearly drowned due to assault. The percentage of patients presenting with fractures was 15.8% for self-inflicted near-drowning patients and only 10.0% for true near-drowning cases. Assault cases had the highest percentage of head injury/contusions (14.3%), whereas true near-drowning cases were mostly recorded as having cuts or open wounds (52.5%) and sprain/strains or bruises (22.5%). There was no statistical significance in proportions between groups, therefore a 95% confidence interval could not be reported.Patients aged 25-44 years accounted for the highest proportion who presented with "near-drowning" complaints ; teenagers and young adults aged 15-24 years contributed to the second highest proportion .  with "near-drowning" presenting complaint. However, none of the true near-drowning patients received triage assessment. Of the 37 true near-drowning patients among whom disposition information was collected, the majority (85.0%) were discharged home from the ED, including those who had follow-up planned and those who needed to return if required by the care provider. A slightly lower proportion of intentional injury patients were discharged home (80.0%) compared with true near-drowning patients. Medical officers and nurse/midwives provided service to the majority of patients . This observation holds when it comes to true near-drowning patients, with 87.5% receiving care from a medical officer, and 80.0% receiving care from a nurse or midwife. An attending physician only provided care to five patients . Due to missing information for the intention of injury, Table The current paper analyzed ED-based information in terms of patients with "near-drowning" presenting complaints, depicting socio-demographic patterns, basic injury-related information, concomitant complaints, and preliminary results for the usage of ED resources in seven participating hospitals in Pakistan. The results show the scarcity of drowning and near-drowning data in Pakistan, even when active surveillance was carried out in major EDs across the country. It also highlighted the similarity and differences between true  near-drowning events and intentional injuries that led to near-drowning complaints. The article further pointed out potential improvements that are needed in building ED capacity and standardizing data collection systems in this nation.The results of the Pak-NEDS study have shown similar injury patterns regarding the sex of patients to studies carried out in other LMICs in the region - males were observed to be more prone to injuries compared with females ,26,27. HThe proportion of intentional injuries with "near-drowning" complaint in this study is considerably high, with half of all cases the result of either assault or self-harm . This fiThe Pak-NEDS study reveals evidence of sub-optimal utilization of emergency medical services (EMS), the most unsatisfying being the 5% utilization rate of emergency vehicles. In 2001, a Pakistan-based study explored the potential explanations for the low utilization rates of emergency vehicles, and concluded that the reasons might include inaccurate recognition of the severity of a patient's condition, unsatisfactory response time of ambulances, inability of some individuals to effectively reach out to an ambulance, as well as unaffordable charge of such services . AlthougFurther, triage was only done for 15% of patients with "near-drowning" complaints, and none for true near-drowning patients. Accurate triage is known for optimizing resource utilization and facilitating the prevention of secondary injury or even death . Only 21One positive observation was that care was generally provided by physicians, nurses, as well as paramedics, which potentially ensures comprehensive care. Interestingly, it is observed in the current study that most of the time junior staff were the first responders when a nearly drowned patient was sent to the ED. Therefore, it is important to train them in the proper management of near-drowning cases. Another relatively reassuring fact was the low hospital admission rate of near-drowning patients, which could be an indicator of high recovery rate of these patients. Nevertheless, this could be a masked result of other undesirable conditions such as limited hospital capacity, lack of in-depth diagnosis, or worse, withdrawal of patients or their families due to financial constraints.The under-reporting of near-drowning events was possible due to a few combined factors. First, while the burden of drowning is significantly higher in rural areas of Pakistan, all participating EDs in this study were affiliated with urban hospitals, which may not truthfully reflect the true burden at the national level . Second,Mortality and morbidity caused by drowning and near-drowning are largely neglected in South Asian countries . Half ofThere are a few limitations in the Pak-NEDS study, some of which have been mentioned above, including under-reporting of drowning and near-drowning in EDs; potential selection bias of ED cases; and the impact of seasonal fluctuation on data collection regarding drowning and near-drowning. One additional limitation is the lack of information on the location of near-drowning events, which can potentially guide interventions to prevent unintentional drowning incidents. Overall, it is important for researchers to note the limitations of ED-based data, which is reflected by the under-reporting of drowning-related incidents in this study. There will also be additional bias due to the higher severity of diseases seen at EDs compared with other departments in a hospital. This factor highly depends on the care-seeking pattern of patients in different countries and regions. It is also revealed that follow-up visits were notably low, which is true for the majority of ED cases reported elsewhere . The difThe Pak-NEDS study is a valuable reminder for researchers to carefully assess the information they need, and measure it against existing data collection systems. Community and household-level data are more preferable in the case of drowning events; however, these kinds of data collection activities can be extremely time consuming and resource intensive, and can hardly exceed the scale of a nationwide ED-based surveillance system. In order to control for temporality or seasonality, subsequent ED-based surveillance should cover a full seasonal cycle--especially for drowning and near-drowning events. As is made evident by many high-income countries, the negative impact of drowning on health systems can be largely reduced through collective actions across multiple sectors - a wide range of strategies can be borrowed from existing HIC preventive programs and modified to suit LMIC settings ,33,40-42The authors declare that they have no competing interests.SH and JCL developed the initial draft. Data management and analysis was done by SH. NZ, URK and KS critically reviewed the draft. AAH designed and supervised the Pak-NEDS study, and critically reviewed the draft. All authors approved the final draft.


I consider two single function hypotheses. First, perhaps the representation of own agency enters into the mechanisms of attention. This seems unlikely as, in general, attention is insufficient for awareness. Second, perhaps, a subject is aware of their sense of agency when it is available for verbal report. However, this seems inconsistent with evidence of a sense of agency in the great apes. Although these two single function views seem like dead ends, multifunction hypotheses such as the global workspace theory remain live options which we should consider. I close by considering a non-functionalist answer to the Hard Question: perhaps it is not a difference in the use to which the representation is put, but a difference in the nature of the representation itself. When it comes to the sense of agency, the Hard Question remains, but there are alternatives open to us.Existing accounts of the sense of agency tend to focus on the proximal causal history of the feeling. That is, they explain the sense of agency by describing the cognitive mechanism that causes the sense of agency to be elicited. However, it is possible to elicit an unconscious representation of one’s own agency that plays a different role in a cognitive system. I use the “occasionality problem” to suggest that taking this distinction seriously has potential theoretical pay-offs for this reason. We are faced, then, with a need to distinguish instances of the representation of one’s own agency in which the subject is aware of their sense of own agency from instances in which they are not. This corresponds to a specific instance of what Dennett calls the “Hard Question”: once the representation is elicited,  In this paper I argue that we, as a community investigating the sense of agency, are not doing enough to answer what Dennett has called the “Hard Question” of consciousness. Our existing models do a very good job of explaining when a representation of own agency is elicited. I illustrate this with two historically important accounts: the comparator model of Frith et al. and Wegner et al. inference to apparent mental state causation. Following Revonsuo, I consider these to be proximal etiological explanations. Although powerful so far as they go, these accounts, on their own, do not provide us with the explanatory resources to distinguish conscious and unconscious representations of one’s own agency. This is not a problem we can ignore. I use the “occasionality problem” to suggest that there are potential theoretical benefits to taking this distinction more seriously as conscious and unconscious representations of own agency play very different roles in cognition. I conclude by considering how we might approach the Hard Question for the sense of agency. I consider two Functionalist approaches (i) that a representation of own agency is conscious if it is taken as the object of attention; and (ii) that a representation of own agency is conscious if it is available for verbal report. Although such approaches offer clear research agendas, both of these specific approaches seem non-starters on empirical grounds. That said multifunction hypotheses such as the global workspace theory remain viable Functionalist positions. Finally I consider a Vehicle theory approach to the Hard Question. Such an approach also offers some clear research questions, but currently no clear answers. As of now, the Hard Question remains under-considered for the sense of agency even though there exist a variety of questions we can ask to make progress on it if we take either a Functionalist or a Vehicle approach. These are questions we would all do well to consider.causes of the sense of agency. Second, the explanations are cognitive explanations. The specific causes posited are mental representations and computations. To understand these accounts as explanations of the sense of agency then, is to understand them as a description of what aspects of the mind, i.e., mental representations and computations, cause a subject to experience their own agency. The sense of agency itself is taken to be just another representation in this causal chain.Standard explanations of the sense of agency are of a particular type. These traits are shared by prominent accounts of the sense of agency. Consider first the comparator model. This model gets its name from the use of three hypothetical comparisons performed by the motor control system. Each of these comparisons performs specific functions for motor control and motor learning , matches an internally generated prediction of what this feedback will be (predicted sensory feedback), a sense of agency is elicited  and represent the action which is occurring or has occurred. Next they must represent that one or other mental state causes the action of their body. This is the role of the inference to apparent mental state causation. According to Wegner et al. this inference is made when three facts about the relationship between the mental state and action are recognized. First, the mental state must be consistent with the action in that it specifies the action that actually occurs. Second, the mental state must seem to occur at an appropriate time before the action occurs, for example a memory of an action won’t be inferred as a cause of that action. Third the thought must appear to be the only possible cause of the action, i.e., if something else, another person or gust of wind, say, could have caused the action then the inference will not be made, or at least not made with a high degree of certainty. Wegner et al. call these the principles of “consistency”, “priority” and “exclusivity” respectively  that on this model it is reasonable to hypothesize that it is the principle of priority which is violated, as there is some evidence that patients suffering from delusions of alien control display abnormalities in the representation of the timing of their actions  again fails to explain why only some actions are misattributed. In essence these accounts suggest that such patients always lack a representation of their own agency, but it seems that this lack only matters to the subject some of the time.Now we are in a position to examine the occasionality problem  is false, quod erat demonstrandum (QED).to the subject. It is the subject noticing  that the sense of agency is absent which is hypothesized to lead to delusions of alien control, not it’s mere absence. This noticing of the absence will occur when the sense of agency is expected and so we might say the absence of a sense of agency is only an anomaly when the subject expects to experience it.To avoid this conclusion, all we need do is drop the assumption that a conscious sense of agency always accompanies our actions. Instead, we need only hypothesize that a representation of own agency which may or may not be conscious accompanies our actions. In other words, the output of processes like the comparator or inference to apparent mental state causation is a representation of the subject’s agency which is sometimes conscious and sometimes not. An absence of a sense of agency is thus not always an anomaly which the patient need explain. An absence of representation is not a representation of absence, as the saying goes, and it is particularly not a representation of absence A possible objection to this line of response is to assert, based on introspection, that a conscious sense of agency accompanies all of our actions in the normal case. As such, it is always expected and any absence is an anomaly to be explained. However, introspection gives us poor grounds to assume that there is a ubiquitous sense of agency. What would lead one to assume that there is a conscious sense of agency accompanying every action? We can see where this assumption comes from, and how poorly grounded it is, by an analogy with visual consciousness. A favorite example purporting to show that we are not conscious of as much as we think we are comes from Dennett . This exWhy do we believe this is true of our peripheral vision? We can speculate on many possible reasons for this. One reason might be that things we use as public representations of what we see, e.g., photographs or videos, are somewhat like this. There may be a misbegotten analogy between visual depictions and visual experience. Another more universal proposal comes from If a model like one of those above is right, then it would be true that our actions are normally accompanied by a representation of our own agency. However, the subject need not be aware of their own agency. The representation could be unconscious but, because the representation is formed with every action, it is there whenever we go “looking” for it, or more generally when it is expected to occur to the subject, i.e., consciously. Just as objects in our periphery always appear clear, distinct and colored when we go looking for them, our representation of agency is always experienced when we go looking for it, thus meeting our expectations. Just as this may lead us to believe that objects in our periphery always appear clear, distinct and colored, this may lead us to believe we always experience a sense of agency accompanying our actions rather than merely representing it.Accepting this conclusion then, the comparator model or the inference to apparent mental state causation need not suppose that representing one’s own agency is always a conscious sense of agency. Still, one may wonder, how exactly does this affect the occasionality problem? After all, it would still seem to be the case that these models predict that the unconscious representation of agency would be missing for every action performed by the patient suffering delusions of alien control, so should the model still predict that the patient would show the delusion for every action?The answer to this is no. However, to see why, we need to return to the purported role of consciousness in the formation of delusions such as delusions of alien control. Recall Maher’s proposal that delusions are attempts to make sense of anomalous experiences. In the case we are interested in here, the delusion of alien control arises because the patient attempts to make sense of the absence of a sense of agency. They expect a sense of agency, but it is not there when they “look”, giving rise to an anomalous experience that must be explained. On this view then, an absent sense of agency is only anomalous when it is expected. A subject would not notice the absence of an unconscious representation. It is only when the representation would otherwise become conscious that its absence would be noticeable. Again the absence of the representation is not the same as the subject representing to themselves that something is absent. The upshot of this is that if we hypothesize that the comparator or inference produces an unconscious representation of agency, which only becomes conscious when it is needed by the subject (say in self-recognition or introspecting to see what experiences one has), we find that the occasionality problem is no problem at all.It is not so much that the problem is solved as it doesn’t arise in the first place, all because conscious and unconscious representations of own agency play different roles in cognition. Only conscious representations can be expected by the subject, and only their absence can be noticed by the subject. The normal case is that actions are not accompanied by a conscious sense of agency (only an unconscious representation) and so a lack of this feeling is typically not an anomaly that the patient suffering delusions of control needs to explain. It is only when they would “look for”  this representation that it is expected and so its absence is an anomaly that needs to be explained.This consideration of the occasionality problem shows us that there are theoretical benefits to taking seriously the distinction between conscious and unconscious representations of own agency. By doing so and considering the different roles conscious and unconscious representations play in cognition we see that the occasionality problem doesn’t arise. As such we don’t need to add assumptions to our models, such as assuming that they only fail some of the time, which lack supporting evidence. However, we do have a new set of issues to consider. What then is the analogy of “looking for” the representation of agency that produces the expectation of the sense of agency needed to explain delusions of alien control? This question is no less than what distinguishes an unconscious representation of agency from a conscious sense of agency, and this is what Dennett has called the “Hard Question” of consciousness.only question is to treat awareness as the end of the line of a computation, the dreaded Cartesian Theatre, and to deny the possibility of an unconscious representation of one’s own agency. In addition to this question, we also need to ask of accounts of agency what Dennett calls the “Hard Question” [not to be confused with any purported “Hard Problems”  simply because their attention is directed elsewhere . In other words the difference is a matter of what is done with the representation. Such approaches are Functionalist theories in that they consider the particular use of a representation within a cognitive system to constitute that representation’s being conscious.Vehicle theories, in contrast, hypothesize that the difference between conscious and unconscious representations is not how they are processed, but in the nature of the representation itself (O’Brien and Opie, capacity to make certain information explicit in the above sense. In general, O’Brien and Opie hypothesize that we are conscious of all and only things that are represented in an explicit form. All unconscious representations would then take the form of potentially explicit or tacit representations.O’Brien and Opie propose a general answer to this question making use of distinctions in kinds of representing vehicles offered by Dennett . In partAccording to this version of a Vehicle Theory, a conscious sense of agency would be an explicit representation of own agency. That is, a discrete vehicle, such as a stable pattern of activity across a layer of neurons (O’Brien and Opie, If such an approach is correct then we have a new way to approach the Hard Question for the sense of agency. How is the output of the comparator model, or whichever account we ultimately agree on, made explicit? Why is it the case that it is sometimes not made explicit? Is this a matter of the subject metaphorically “looking for” it, if so, how would that be understood more literally?then what happens?The benefit of taking this approach is that it offers a new kind of answer to the Hard Question by offering a new conception of what properties of a computational system distinguish conscious from unconscious representations. With this reconceptualization we can deploy O’Brien and Opie’s hypothesis for the sense of agency and answer the Hard Question in a way that doesn’t seem to be falsified like the other answers considered here. In addition, a research agenda is set: why and how is a representation of own agency sometimes made explicit? Of course this question has not yet been answered. Indeed whichever form of the Hard Question we prefer it is clear that we have not yet answered it, although there seem to be two promising avenues to approach it. And so I implore us, as a community to ask of ourselves, now that we have made progress in understanding how a representation of own agency is elicited, In this paper I have argued that in order to explain the sense of agency we need to move beyond proximal etiological explanations and consider the Hard Question. Although such accounts, including the comparator model and the inference to apparent mental sate causation, are powerful so far as they go, they fail to distinguish between conscious and unconscious representations of own agency. As a consideration of the occasionality problem suggests, not only is this a real distinction, but such representations can play very different roles in cognition. Finally, I have suggested that there are ways we can approach the Hard Question, and although some of the specifics of certain particular approaches might seem like non-starters on empirical grounds it should be clear that there are alternative approaches, both Functionalist and vehicle, available and specific questions to ask. Now what happens?The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Objective. To explore the implementation of incident learning for quality management of radiotherapy in a new established radiotherapy program. Materials and Methods. With reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically established for reporting, investigating, and learning of individual incidents. The incidents that occurred in external beam radiotherapy from February, 2012, to February, 2014, were reported. Results. A total of 28 near misses and 5 incidents were reported. Among them, 5 originated in imaging for planning, 25 in planning, and 1 in plan transfer, commissioning, and delivery, respectively. One near miss/incident was classified as wrong patient, 7 wrong sites, 6 wrong laterality, and 5 wrong dose. Five reported incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity. For the causes/contributory factors, negligence, policy not followed, and inadequate training contributed to 19, 15, and 12 near misses/incidents, respectively. The average incident rate per 100 patients treated was 0.4. Conclusion. Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety. With the rapid development of equipment and technology, the technique of radiotherapy becomes more and more complicated. The treatment planning and delivery of radiotherapy are a highly complex, multiple-step process, with multiple professional groups involved. Every step of the care process in radiation oncology requires knowledge in the management of cancer and certain benign disease, radiobiology, medical physics, and radiation safety that can only be achieved by systematic and structured training. There are many steps where incidents might occur, although major radiotherapy incidents are rare. And it is challenging to determine the actual error rate in radiotherapy. The quality management of radiotherapy is paramountly important to guarantee the appropriateness, quality, and safety of radiotherapy.As a systematic tool and approach of quality management, incident learning has proved its value in many industries . It has While it is generally accepted that incident learning is important in the radiation therapy setting, implementing incident reporting and learning represents a considerable challenge. It requires additional clinical resources and a well-designed system for report, analysis, and response. What is more important is the development of a more open mindset and just culture for reporting near misses and incidents, with an increased emphasis on incident learning to uncover latent error pathways. Studies analyzing the effects of incident learning on patient safety and quality in individual clinics remain scarce, while several departments reported their experience –13.The purpose of this work is to explore the implementation and effectiveness of incident learning using a system developed based on AAPM recommended database structure in a new established program of radiation oncology with advanced technology.Our department of radiation oncology is a comprehensive clinical and academic department with new established external beam radiotherapy program, delivering 537 treatment courses on Trilogy  in 2012 and 725 treatment courses on Trilogy and Axesse  together in 2013. Trilogy and Axesse were put into clinical use after commissioning on February 2012 and April 2013, respectively. The comprehensive record-and-verify/information system of Aria  and Mosaiq  were used for Trilogy and Axesse, respectively. All the simulation, planning, delivery, and information systems were newly installed and commissioned. All the protocols and quality management programs were established from scratch. For simulation, Brilliance Big Bore CT  was used. Eclipse and Oncentra  treatment planning systems were mainly used for planning, in addition to Pinnacle  and Monaco systems. Most of the staff had no previous intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT) experience. The techniques utilized included three-dimensional radiotherapy (3D-CRT), IMRT, IGRT, volumetric modulated arc therapy (VMAT), gated treatment, ultrasound guided radiotherapy, four-dimensional (4D) cone beam computed tomography (CT), and Hexapod  treatment couch with six degrees of freedom. The plans were transferred electronically to the record and verify system by Digital Imaging and Communications in Medicine (DICOM). All the plans were checked by senior physicist after radiation oncologist approval, before treatment. At treatment, the therapist rechecked the transferred data with printed plan data and treatment chart parameters.With reference to the consensus recommendations for incident learning database structures in radiation oncology by American Association of Physicist in Medicine (AAPM), an incident learning system was specifically designed and developed for reporting, investigating, and learning of individual external beam radiotherapy incidents in our department. The definitions, process maps, severity scales, causality taxonomy, and data elements were referred from AAPM recommendation. The definitions of terms were clarified. 91 common steps were identified for external beam radiation therapy, 35 safety barriers were set. A ten-level dosimetric and medical severity scale were used to reflect the observed or estimated harm to a patient and a radiation oncology-specific root causes table was used to facilitate the root-cause analyses. Near-miss incidents were assigned with the estimated harm that would have occurred had the incident reached the patient.We applied the definitions of terms in accordance with the consensus recommendations American Association of Physicist in Medicine (AAPM) . An inciAfter pilot testing, clinical staff used the system for reporting the incidents that occurred in clinical practice. The incidents reported in the system were then investigated, analyzed, and learned by a multidisciplinary team which includes the leaders of radiation oncology, radiation physics, and technologists. The priority of our implementation strategy was to strenuously promote staff acceptance and participation through emphasis of senior management participation and expectations with respect to the establishment of a just environment. It was also to promote openness about reporting incident, emphasis on learning and support, and an obligation to act, where all staff members felt comfortable disclosing incidents while maintaining professional accountability. The established multidisciplinary team directs the reporting, investigation process and determines the corrective actions and follow-up, as required to ensuring prompt response and feedback.The reporting process starts with the initial reporter who submits the initial description of the event. The event is then forwarded to supervisors of the involved areas by the team leader (the chief of the department). In our implementation, even though there may be several areas involved in the event, each event is processed by only one supervisor who performs the initial analysis of the event and determines the best approach for corrective action. Which supervisor is selected to address an event depends on the main area of involvement and on which supervisor believes to be in the best position to address the issue. Each supervisor can review other supervisor's comments and event disposition. This transparency and active involvement of supervisors in event processing contributed significantly to the uniformity of event processing by different supervisors.The investigation of the incidents was addressed individually by a small number of key supervisors. A full team investigation is used for the more serious incidents and for the incidents where the determination for the basic cause and identification for the most appropriate learning component requires more rigorous assessment. Immediately after reporting or monthly all reported incidents were reviewed at the department multidisciplinary quality management forums. As we collect a broad spectrum of events, from minor near misses to potentially serious incidents, the event processing can vary significantly from one event to another, and this process evolved over time as our clinic gained experience with the system. Low severity events that have already been addressed and at first do not appear to require systematic process changes, such as minor work flow variation or deviation near misses, are typically only classified and cataloged so that their statistics can be reviewed at a later time. Events that are indicative of process weaknesses or the need for training are immediately addressed by the supervisor, who initiates procedural changes or schedules the necessary training. These events are typically judged to be essential for the system operation and corrective actions are relatively simple. The event severity is reviewed and assigned by the supervisor during the investigation and review of the event. Events are subsequently processed based on the severity classification. More complex events that require significant corrective actions are forwarded to the department Process Improvement Committee for further discussion and processing.All relevant cause/contributory factors were investigated and assigned by the investigating team, from the aspect of management, technique, personnel, equipment, and process, since it is a rare situation in which only one single cause is at work, so that a full root-cause analysis can be implemented. In addition, each discipline was further discussed or reflected on the data within their own specialty, focusing on process breaks and system errors, intent to find means of preventing reoccurrence. Departmental no blame policy was advertised repeatedly encouraging staff to report incidents without fear of retribution. Blaming an individual or group as the only root cause may lead to corrective actions that fail to address an underlying cause. An individual's actions must be viewed in the context in which they act when performing root-cause analysis. Each reporter can know about all events that they have submitted along with the analysis performed by the supervisor and the ultimate disposition of the events.Learning actions included focused education sessions on a specific process to highlight error risk, process mapping, protocol changes, quality control measures and approaches of prevention of errors and continuous improvement, discussion with specific workgroups to make them aware of any error risk that has been identified, and presentations at chart rounds. The incident learning was used for guidance in reengineering clinical processes. The data and the statistics collected through the established database were presented at the department quality improvement conference with the corrective actions, thus allowing easy communication of problem details and corresponding process modifications.The reported external beam radiotherapy near misses and incidents were presented from February 2012 to February 2014. The reporting trends for the second year were compared to the events that were reported in the first year.A total of thirty-three reports were analyzed, including 28 near misses and 5 actual incidents. During this period, a total of 1262 patients were treated. The summary of reported near misses and incidents are given in Of the 6 wrong laterality near misses/incidents, 4 occurred due to the contouring and planning at the wrong  side of the body, 2 due to wrong patient position selected in the CT scan protocol , which were found during the image guided verification before treatment.Of the 7 dose prescription near misses/incidents, 2 near misses occurred due to the erroneous planning instructions in the prescription, 1 inconsistent prescription in terms of total dose, dose per fraction, and fractions (PTV 50.40 Gy/1.8 Gy/25 f). The other 4 occurred due to planner not following the physician's prescriptions, including significant error of prescription of 60.00 Gy/2.0 Gy/30 f, plan with 60.00 Gy/0.3 Gy/200 f.Of the 5 wrong dose near misses/incidents, 1 dose calculation error occurred due to the misunderstanding of source axis distance (SAD) factor for manual dose calculation by the junior physicist, which was found and corrected during physics review. The second near miss was an error in absolute dose calibration of electron beam during commissioning of Trilogy which would result in approximately 60 patients treated with a dose 5% below that prescribed per year if not found. This near miss was caused by wrong understanding of the calibration protocol, found, and corrected in physics review. As the cause was a single error, this incident was categorized as one incident despite the impact on a large number of patients if not detected. The other reasons of wrong dose error included insufficient scan field of view, not enough air flash in planning.The reasons of the 7 reported suboptimal plan quality near misses/incidents included incomplete contouring of organs at risk, not optimal in selection of beam energy, margin setup, intermediate, and low dose distribution.The incident breakdown by origin is shown in Of the 33 incidents and near misses reported, 5 originated in imaging for planning, including error/miss marking reference point on patient in software for three patients, error in input patient position (head first instead of foot first) in CT scanner during CT image acquisition for two patients. Of the 25 incidents/near misses originated in treatment planning, seven originated in the preliminary prescription parameters, including 3 wrong prescriptions from oncologist and 4 due to planners not following physician's prescription in terms of fractions, dose per fraction, and total dose. 11 near misses/incidents originated in dose distribution optimization leading to suboptimal plan. The other near misses/incidents included 4 due to targets contoured and planned on the wrong side , 1 organ at risk  incompletely contoured leading to overdose if delivered, 1 treatment plan parameter transfer error due to the network issue, and 1 manual dose calculation error for a patient simulated with conventional X-ray simulator, due to the wrong understanding of SAD factor.The dosimetric and medical severity distribution of reported near misses and incidents are given in Tables The summary of the root causes and contributory factors to the near misses/incidents are given in Our results demonstrated that incident learning can be used for the safety and quality management of radiotherapy, even for a department with new established program with advanced technology, new equipment from different vendors, no much safety, and quality management experience. Implementation of an effective incident learning system may serve to reduce the occurrence of actual incidents and enhance the culture of safety at the individual health care professional level and at the multidisciplinary team level by addressing quality improvement initiatives collaboratively with transparent accountability. Incident learning also improved event communication and identification of clinical areas which needed process and safety improvements and encouraged the reporting of potential incidents as a proactive means of enhancing safety and quality in a radiation treatment program. The reported data were also useful for the evaluation of corrective measures and recognition of ineffective measures and efforts.Implementing Incident learning in radiotherapy is a systematic and complicated project. A rigorous system of learning, feedback, and action are required for this approach to have a meaningful impact on patient care. The corresponding departmental infrastructure and facilities, organization, and culture are needed. The related academic society, organization, and state health administrative department should encourage and protect the reporting and learning of near misses/incidents by advocacy, regulation, and legislature. Step by step improvements are needed for incident learning fully implemented in radiotherapy.AAPM recommended database structure provided a very good reference for establishing individualized database for individual institution. A reporting system easy to use, file, report, respond, and analyse could be established based on that considering of the context of individual department. The individual events could be quickly and easily reported without disrupting clinical work. The specially designed incident reporting systems in a radiotherapy setting can provide valuable data for process and patient safety improvement. There are some differences in the work process map and quality control program for different institutions, such as using CT simulator for couch shift and isocenter determination before treatment in our department, in which 7 near misses were found and corrected. There is no this process in the AAPM recommended database structure. Only one near miss and two incidents occurred in the safety barrier of the radiotherapy process of the 33 reported near misses/incidents. Erroneous prescription instructions and failure to follow the physician's prescriptions lead to 7 dose prescription near misses/incidents, but no safety barriers were set from prescription and planning to plan review whether for physician, planner, or physicist. Only physics review was set as safety barrier in the AAPM recommended structure. So, the setting of safety barrier should be catered to the individual context of the department. Safety barriers should be added before plan review to reduce errors and delay and improve efficiency. Cox et al.  found moIn addition, the severity assignment of an actual incident or near miss is difficult, especially for the near-misses since one has to estimate the harm that would have reached the patient several steps down the chain of events. The dosimetric severity scale could not fully be expressed by dose; it will be better if evaluated with biological effective dose. For a near miss reported in our study, in which the physician's prescription of 60.00 Gy/2.0 Gy/30 f was planned with 60.00 Gy/0.3 Gy/200 f, the dose was the same, but it would result in severe effect if not found.33 near misses/incidents were reported in two years in this study. The volume of reports varies with the report criteria, quality and safety culture, equipment, and techniques used for different institutions. Mutic et al. have observed an incident report rate of 1 per 1.6 patients treated (this includes both incidents that reach the patient and near-miss incidents that are intercepted before reaching the patient) . We collThe rate of reported near misses/incidents decreased significantly in the second year, although more near misses of suboptimal plan quality were reported due to the enhanced quality and safety culture in the second year. The high rate of reported near misses/incidents in the first year may be attributed to the introduction of new equipment, new techniques, and new staff. Through the analysis of the occurrence of near misses/incidents, the cause/contribution factors, we found the weaknesses in the clinical process and implemented series of proactive measures to enhance the safety and quality. At the start of 2013, we introduced a more comprehensive check list in an attempt to reduce these errors and the error rate fell dramatically. Morganti et al. report a reduction in error through the use of independent checks . Clear cAn important feature of the incident learning system is that it requires an investigation of sufficient depth to discover the basic causes of an incident according to a predetermined categorization and thereby facilitate the determination of meaningful corrective actions. An added benefit of such an approach is that it enables the identification of system problems or basic causes that could precipitate a range of different incidents. If the basic causes are addressed, it can be expected that overall system safety is enhanced and not just a particular weakness associated with a particular incident. The distribution of basic causes demonstrated that negligence and training contributed the most to the errors. It is understood for the new established program with new staff. The decrease of the number of these factors also demonstrated the effect of enhanced training and continuing education. Following that was policy not followed which was associated with a significant proportion of errors. The number of near misses/incidents assigned a basic cause relating to policy not followed was 12 and 3 for the first and second year, respectively. The reducing of these numbers indicated that the culture of following policies and procedures may be improving, which was also shown as the rising number of suboptimal plan quality near misses. There were still a significant number of near misses occurred due to failure to develop an effective plan, which showed the challenge of long term continuing education and personnel capacity improvement.Systematic, scientific, efficient, and feasible management tool and approach is needed for the safety and quality management of radiotherapy. The aim of the incident learning was to capture of potential as well as actual incidents, engender a culture of safety, and support process improvement in patient care and safety. Incident learning can be used individually or combined with Failure Modes and Effects Analysis (FEMA), PDCA circle, and six sigma. Incident learning permits the implementation of both proactive and reactive error management initiatives, leading to quality improvement in all aspects of the clinic's operation and this strategy. A clear understanding of the potential consequences and relationships between different incident types will guide incident reporting, resource allocation, and risk management efforts. Additional work is needed to develop methods that can more effectively utilize reported data for process improvement.Our results show that implementation of an effective incident learning system may serve to reduce the occurrence of actual incidents, enhance the culture of safety, and encourage the reporting of potential incidents as a proactive means of enhancing safety and quality in a radiation treatment program. Incident learning can be used for the safety and quality management of radiotherapy according to our primary experience.


The massive fluctuations occurring in Russian alcohol-related mortality since the mid-1980s cannot be seen outside of the context of great social and economic change. There is a dearth of qualitative studies about Russian male drinking and especially needed are those that address social processes and individual changes in drinking. Conducted as part of a longitudinal study on men’s alcohol consumption in Izhevsk, this qualitative study uses 25 semi-structured biographical interviews with men aged 33–60 years to explore life course variation in drinking. The dominant pattern was decreasing binge and frequent drinking as men reached middle age which was precipitated by family building, reductions in drinking with work colleagues, and health concerns. A minority of men described chaotic drinking histories with periods of abstinence and heavy drinking. The results highlight the importance of the blue-collar work environment for conditioning male heavy drinking in young adulthood through a variety of social, normative and structural mechanisms. Post-Soviet changes had a structural influence on the propensity for workplace drinking but the important social function of male drinking sessions remained. Bonding with workmates through heavy drinking was seen as an unavoidable and essential part of young men’s social life. With age peer pressure to drink decreased and the need to perform the role of responsible breadwinner put different behavioural demands on men. For some resisting social pressure to drink became an important site of self-determination and a mark of masculine maturity. Over the lifetime the place where masculine identity was asserted shifted from the workplace to the home, which commonly resulted in a reduction in drinking. We contribute to existing theories of Russian male drinking by showing that the performance of age-related social roles influences Russian men’s drinking patterns, drinking contexts and their attitudes. Further research should be conducted investigating drinking trajectories in Russian men. Heavy and hazardous alcohol use is an important driver of the Russian male mortality crisis, and since 1980 there have been large parallel fluctuations in population-level drinking and premature death . PreviouPrevious qualitative studies have highlighted how Russian male heavy drinking is related to demonstrations of masculinity, and is more common in male-dominated environments such as blue-collar workplaces ,10,11. Tblat  to keep warm (#10)”, “the radiation we get because of the job, we have to get rid of it somehow”(#4)).Periods of heavy drinking in young adulthood were often associated with particular workplaces or institutions , type of work or shift pattern . Some roles provided greater access to alcohol at work because ‘technical’ spirits were used to clean equipment and could be misused for drinking (“kollektiv’ (a Soviet-era term for work brigade) they belonged to was crucial in determining drinking habits. Because Russian men’s socialising typically involves drinking, and work commonly provides the primary social identity for Russian men  near work, at employees’ cafés, or on the journey home ). A minority described resisting pressure to drink heavily but non-conformity usually meant missing out on social events, which risked weakening of social relations and influence. Changes in the kollektiv and losing touch with old colleagues were associated with drinking declines, and these was described with nostalgia and regret because the men missed the camaraderie and friendship bonds drinking had created: “We still go, but the group became smaller… and before the occasions were bigger. A big group of us would stay for longer for any reason” (#9).Several interviewees stated explicitly that the ‘sian men , a stronOver time employers’ anti-drinking policies had become stricter and directly restricted workplace drinking. In addition workers themselves felt an increased sense of responsibility and job insecurity compared with Soviet times when employment was taken for granted. Management monitored drinking more rigorously using more advanced technologies, and if caught drunk the penalties were more severe:“Well my work was more relaxed, when I would come smelling of alcohol they would just slap your wrist but now it’s all official, first they give you a warning and if you get caught for the second time you lose your job”(#15)in the good old days someone would come and offer a beer or two or and maybe some vodka” (#15)).Although reduced since Soviet times, there were some contemporary accounts of workplace drinking which described lax anti-alcohol policies; in one example from a factory environment drinking sessions and even choice of the beverage were led by the manager ((I drink) vodka, because the manager doesn’t drink beer…so we all have to follow his example (#4)).Sharing a bottle during the work shift was described nostalgically , and a reoccurring theme was the controlling wife:Sometimes men felt coerced to reduce their drinking because family members monitored their habits -“So she is against you drinking completely, or against you drinking too much, which one?”-“Just too much, so that I can walk home, do some chores round the house, and go to work normally”My youngest daughter was born and after that things changed”(#21); “I met my girlfriend and that was a good stimulus for me to stop”(#12)). The demands of spending more time with family and acting as a good role-model to their children  superseded social pressure to drink with work mates or friends. In many cases this was not described as a conflict but accepted as a normal transition:This social control of drinking within marriage  is consi“Before when I got my wages, I would hang around with my friends, but now I come back to her and talk about how to make it stretch…nothing has changed [in terms of quality of life], just we are getting older and wiser.”(#17)the age of 35–40…people above that age tend to drink less, from what I see” (#1). Some described the craving to drink inexplicably lessening with age:The shift in emphasis from heavy drinking with workmates to more moderate drinking was mostly perceived as unremarkable, something that ‘just happened’, and part of the pattern of ageing: ““There was a sort of change. When I was about 30 years old, probably 35, there was a kind of tug, a pull, you understand. You go somewhere after work? So you drink…. And now, I simply don’t know how now it can be, just drinking and drinking. Well, sometimes I would hang out in company, and then I would say to them “If you want to- drink”. I don’t want to and that’s it.”(#1)I loved to dance while drunk. Now it’s awful because I am not allowed to walk quickly” (#25)). However several interviewees described cutting down on drinking as a conscious decision which originated from a desire to gain control over their habits and health ). Sometimes this was stimulated by seeing their heavy drinking friends getting ill or dying, or by noticing alcohol’s health effects on themselves . Having a sense of mastery over alcohol, of knowing your personal limits, was expressed with some confidence and pride: “We know our dosage, we know our limit very well” (#23); “I am trying to behave myself in that respect now. Before I had less discipline” (#14). Car ownership, an important status signal for Russian men, was also described as a prohibiting factor, as they feared being caught drink-driving and thus losing this marker of mature social status.In other cases health concerns curtailed drinking “My wife is constantly ill… She has invalidity and doesn’t work. They removed her bladder, for a long time she lived without going to the toilet. I began to drink more vodka.”(#8)kodirovaniye), which usually refers to a suggestion-based method where the narcologist persuades the patient that they have altered their brain so that alcohol consumption is physically dangerous [my wife was nagging me about it” (#24)) and others had feelings of personal failure inducing them to seek help. Some broke their coding and returned to heavy drinking as a way of coping with personal tragedy, accidents and stress. Those who successfully completed the period of abstinence under coding also returned to drinking afterwards.Dramatic fluctuations were sometimes associated with undergoing the alcohol treatment popularly known as coding The narratives presented here describe changes in drinking over a period of enormous social and economic instability. Within this context unexpectedly the most dominant drinking pattern trajectory in our study was a decline in heavy and hazardous drinking with age. Decreases were often attributed to ageing and ‘inevitable’ shifts in personal priorities over the lifetime from male bonding with colleagues in youth to performing the responsible breadwinner role for their wife and family. Drinking trajectories were heavily embedded in expectations of age, gender, and status-appropriate behaviour. The few men who had drinking increases or sharp fluctuations also tended to have more unconventional employment or family histories, and although it is difficult to know the direction of causality it is likely heavy drinking and social problems are mutually reinforcing .Our study sheds light on alcohol use dynamics in Russia, which together with other Eastern European countries has the highest rate of alcohol-attributable deaths in the world, estimated to be 10 times higher than in other world regions . MoreoveConsistent with other studies this study showed that the construction and performance of Russian masculine identity is entwined with heavy drinking ,38,44 ankollektiv and through more structural means such as availability and the institution’s alcohol policy. This was not only true of Soviet-era plants, but also for some contemporary industrial workplaces. In addition workplaces also influenced drinking directly through (non-)enforcement of the company alcohol policy, the availability of non-beverage alcohol at work, and the strategic positioning of alcohol kiosks around workplaces. These factors work together to create an ‘alcogenic’ environment [In young adulthood the blue-collar workplace was a crucial site for the formation and reinforcement of male drinking norms, both through the cultural ‘habitus’ of the ironment . FurtherLife course reductions in drinking can be interpreted within the framework of social conformity to age-based masculine norms. Russian men assert their masculinity in different ways over their life course, which has implications for their drinking pattern. Young men are more likely to drink heavily and hazardously while socialising with their workmates which helps to develop the strong friendships and instrumental social networks important for securing stable employment and a reasonable standard of living. By contrast, as men reach their late 30s or middle age, they are expected to become reliable breadwinners and provide a good role model for their children , at whicThe influence of age-based norms on Russian men’s drinking may become less important, however, in times of acute social stress and instability, particularly when employment and maintaining breadwinner status are threatened. The population-level increases in alcohol-related mortality in the economically unpredictable 1990s and at the time of the 1998 rouble crisis  and micrOur study had some limitations. Many of the accounts of drinking are historical and further research is needed to understand alcohol in the contemporary Russian workplace. Despite purposive sampling we ended up with mostly accounts of drinking decreases. Whether this represents a survivor effect or selection bias is less important than our missed opportunity to explore increases in detail. Seven men had participated in an earlier motivational interviewing trial, and while this was not found to be significantly effective , it coulThis study is unique in exploring detailed alcohol use trajectories in Russia, where men’s alcohol-related mortality is a serious public health issue. The results highlight the importance of blue-collar workplace socialising for conditioning patterns of hazardous drinking, but also that this could be a potentially successful intervention site. Further research should be conducted focussing on alcohol in a variety of contemporary workplaces, and to investigate the trajectories of men who weren’t in this sample due to survivorship or other issues. The study also highlights the importance of considering social conformity to both age-and gender norms for influencing health behaviours in Russia.S1 Dataset(DOCX)Click here for additional data file.


It is known that intensive training and expertise are associated with functional and structural neuroadaptations. Most studies, however, compared experts with nonexperts; hence it is, specifically for sports, unclear whether the neuroplastic adaptations reported are sport-specific or sport-general. Here we aimed at investigating sport-specific adaptations in professional handball players and ballet dancers by focusing on the primary motor and somatosensory grey matter (GM) representation of hands and feet using voxel-based morphometry as well as on fractional anisotropy (FA) of the corticospinal tract by means of diffusion tensor imaging-based fibre tractography. As predicted, GM volume was increased in hand areas of handball players, whereas ballet dancers showed increased GM volume in foot areas. Compared to handball players, ballet dancers showed decreased FA in both fibres connecting the foot and hand areas, but they showed lower FA in fibres connecting the foot compared to their hand areas, whereas handball players showed lower FA in fibres connecting the hand compared to their foot areas. Our results suggest that structural adaptations are sport-specific and are manifested in brain regions associated with the neural processing of sport-specific skills. We believe this enriches the plasticity research in general and extends our knowledge of sport expertise in particular. Numerous studies have shown that the human brain changes its structure and function as a consequence of training, expertise, and environmental influences throughout the entire lifespan –4. TheseTo the best of our knowledge there are only three previous studies comparing two different groups of athletes. First, this is the work recently published by Chang and colleagues  who inveIn two previous studies of our group , 19 the  en dehors. This constant outward rotation of the legs starting in the hip, so that knees and feet are turned outward, forms the basis of ballet. Every sequence of dancing steps must start and end with one of five basic positions . Specifications, such as toe dancing (en pointe), further increase complexity [Classical ballet dancing is a very demanding and well-defined form of dancing requiring not only high levels of physical strength, balance, and flexibility , but alsmplexity . In addimplexity .jump shot), for instance, is comprised of a three-step rhythm (left-right-left) towards the goal, in which a right-handed player jumps off with the left leg, throws the ball with the right hand, and cushions the jump with the right leg before landing again on both feet [Contrary to classical ballet, the main focus of handball lies on physical abilities involving both hands. In addition to general physical aspects such as running, jumping, endurance, mobility, speed, and skills, throwing the ball including throwing speed represents major facets of a successful player . The basoth feet .Due to the fact that the feet are more important in ballet dancers and the hands are more important in handball players, we expected to find differences in the M1 and S1 representations of the hand and foot indicated by greater GM volume alterations in the hand areas of handball players compared to greater GM volume alterations in the foot areas of ballet dancers. We also predicted differences in the white matter fibres connecting the hand and foot representations via the CST indicated by greater alterations in FA of fibres connecting the foot areas in ballet dancers and of fibres connecting the hand areas in handball players, respectively.We investigated 44 women aged between 18 and 37 years  = 3.83 years) of whom 10 are professional ballet dancers , 12 are professional handball players , and 22 are control women . The control group is composed of the same control participants of the before mentioned two previous studies of our group with 10 control women of the ballet study . In ordeMRI scans were acquired on a 3.0 Tesla Philips Intera whole body scanner  equipped with a transmit-receive body coil and a commercial eight-element head coil array which is capable of sensitivity encoding (SENSE).3  and reconstructed to a resolution of 0.86 × 0.86 × 0.75 mm3 . It is important to note that this type of MRI signal interpolation does not have an adverse effect on the quality of the data and we do not suggest that our MR images are of a better spatial resolution than the measured one of 1 × 1 × 1.5 mm3. Further imaging parameters were field of view FOV = 220 × 220 mm2, echo-time TE = 2.3 ms, repetition-time TR = 20 ms, and flip-angle α = 20°.Handball players and ballet dancers (and their corresponding control participants) had identical T1-weighted images. A volumetric 3D T1-weighted gradient echo sequence (turbo field echo) image was measured with a spatial resolution of 1 × 1 × 1.5 mm3  and a reconstructed spatial resolution of 1.72 × 1.72 × 2.5 mm3 . Further imaging parameters were FOV = 220 × 220 mm2; TE = 50.0 ms; TR = 11,300 ms; α = 90°; SENSE R = 2.1; b-value b = 1,000 s/mm2; and number of averages = 2. Diffusion was measured in 15 noncollinear directions preceded by a non-diffusion-weighted volume (reference volume). For ballet dancers, a diffusion-weighted spin echo, echo-planar imaging sequence was used to obtain diffusion-weighted scans with a measured spatial resolution of 2.08 × 2.13 × 2.00 mm3  and a reconstructed spatial resolution of 1.56 × 1.56 × 2.0 mm3 . Further imaging parameters were FOV = 200 × 200 mm2; TE = 50.0 ms; TR = 10,166 ms; α = 90°; SENSE R = 2.1; b-value b = 1,000 s/mm2; and number of averages = 2. Diffusion was measured in 15 noncollinear directions preceded by a non-diffusion-weighted volume (reference volume).Handball players and ballet dancers (and their corresponding control groups) had slightly different diffusion-weighted sequences. For handball players, a diffusion-weighted spin echo, echo-planar imaging sequence was used to obtain diffusion-weighted scans with a measured spatial resolution of 2.29 × 2.34 × 2.50 mmhttp://fsl.fmrib.ox.ac.uk/fsl/fslwiki/FSLVBM), an optimised VBM protocol [http://www.fmrib.ox.ac.uk/fsl/). First, structural images were brain-extracted and GM-segmented before being registered to the Montreal neurological institute (MNI) 152 standard space using nonlinear registration [x-axis to create a left-right symmetric, study-specific GM template. Second, all native GM images were nonlinearly registered to this study-specific template and “modulated” to correct for local expansion (inflation) and contraction (deflation) due to the nonlinear component of the spatial transformation. The mean values of the regions of interest (ROIs) (see below) were then extracted from the unsmoothed GM volume maps.Between-group differences in GM volume were evaluated by using VBM , 31. T1-protocol  which isprotocol  (http://stration . The reshttp://www.fil.ion.ucl.ac.uk/spm/). The coordinates of the eight ROIs  were drawn from a study that actually investigated the somatotopic organisation of cerebrocerebellar connections in 1000 subjects using fMRI in the resting state, but this study also localized the hand, foot, and tongue representations by using motor-task fMRI in 26 subjects [M1/R  and FOOTS1/R  overlap with a radius of 8 mm, we shifted the x-coordinate from 6 to 9 mm for M1 and from 10 to 9 for S1. The same shift was applied to the FOOTM1/L  and FOOTS1/L ; that is, the x-coordinate was increased from −6 to −9 for M1 and reduced from −10 to −9 for S1. The Montreal neurological institute (MNI) space coordinates are summarised in In the present study we focused on the M1 and S1 representation of the hands and feet as well as on their white matter connections via the CST to the brain stem. Spherical ROIs with a radius of 8 mm were created using the WFU Pickatlas , 37 implThe reason why we used the MNI coordinates of the above-mentioned study  is that x = 6, y = −36, and z = 70, which is comparable with the coordinates used for our ROI of FOOTM1/R with x = 9, y = −26, and z = 76 and suggests that translocations (shifts) of these functional areas have not been expected. Third, by way of visual inspection we are able to show that the hand ROIs used to extract GM values do fully cover the omega-like shaped primary motor hand representation in our athletes.First, potential shape differences in the hand and foot representations between sportswomen and nonsportswomen will be taken into account and adjusted for by the nonlinear spatial transformations applied during preprocessing. Second, by way of comparison, in the study of Wenzel and colleagues , for exaThese ROIs were used for the extraction of GM volume based on T1-weighted MRI scans but also served as seeds and targets in the probabilistic fibre tractography of the CST from these ROIs to the brainstem and from the brainstem to these ROIs (see below) based on DTI data.DTI data preprocessing and probabilistic fibre tractography were performed with FSL version 5.0.5. In a first step, nonbrain tissue was automatically removed using FSL's brain extraction tool. Further automated preprocessing steps (eddy-current and head movement correction) as well as the construction of individual diffusion tensor, FA, axial diffusivity (AD), and radial diffusivity (RD) maps were performed using FSL's diffusion toolbox 2.0 . Even thM1/R, FOOTM1/L, FOOTS1/R, FOOTS1/L, HANDM1/R, HANDM1/L, HANDS1/R, and HANDS1/L) and an additional planar ROI placed on the height of the brainstem (MNI coordinate z = −22) tracking was performed from each cortical ROI (seed mask) to the brainstem ROI (waypoint and termination mask). An exclusion mask was set for the homotopic ROI in order to exclude fibres that might run across the corpus callosum to the opposite hemisphere. Default tracking parameters were used. Resulting tracts were in MNI space. After fibre tractography, within-tract probabilistic values were normalised at the individual level by dividing the number of streamlines passing through each voxel by the total number of obtained streamlines  [Using the above defined eight ROIs  . SubsequDue to the fact that some voxels representing CST were included in both tracts, that is, in the reconstructed fibres running to the hand areas as well as in those running to the foot areas, these overlapping voxels were excluded in order to obtain FA, AD, and RD values that are associated with fibres connecting either the hand representations or fibres connecting the foot representations without any overlap of fibres connecting both representations.http://www-01.ibm.com/software/analytics/spss/products/statistics/) were applied. Error probability was set at p < 0.05.For the comparisons of demographic indices and global brain measures between ballet dancers, handball players, and controls, one-way analysis of variance (ANOVAs) models using IBM SPSS Statistics software version 22  and the mean FA, RD, and AD values, respectively, of each of the eight CST tracts , these data was analysed using IBM SPSS Statistics software version 22. All data was tested for normality using the Kolmogorov-Smirnov test. We performed multifactorial, multivariate analyses of variance for repeated measures (rmMANOVAs) for the dependent variable GM volume as well as for FA, RD, and AD. We constructed both a 2 × 2 × 2 × 2 design with the between-subjects factor GROUP  and, in order to additionally include a control group, a 3 × 2 × 2 × 2 design with the between-subjects factor GROUP  and the within-subjects factors BODYPART , MODALITY , and HEMISPHERE , respectively.These analyses were performed once with the absolute ROI values and once with relative ROI values, that is, with normalised values. For the relative values, the absolute ROI values were divided by a global measure. For ROI GM volume, we used total global GM volume and for ROI FA, RD, and AD we used mean global FA, RD, and AD, respectively. In case of significant differences between the groups Tukey's HSD post hoc tests were applied.t-tests for independent samples were additionally performed between the handball players and the ballet dancers. Pearson correlations were used to associate the GM and FA findings with age of training commencement and years of training to associate the GM changes with the FA changes. Both t-tests and Pearson correlations were corrected for multiple comparisons by means of the false discovery rate (FDR). Effect sizes are reported based on the correlation coefficient r (correlations), Cohen's d (t-tests), and partial eta-squared . According to Cohen, effect sizes are denoted small if r = 0.10, d = 0.20, and ηp2 = 0.01, denoted moderate if r = 0.30, d = 0.50, and ηp2 = 0.06, and denoted large if r = 0.50, d = 0.80, and ηp2 = 0.14.Only to support the rmMANOVA findings, p = 0.049). With respect to mean RD and AD there were significant differences between the groups  = 4.53, p = 0.017; AD: F = 4.47, p = 0.018). However, as post hoc tests revealed, these significant differences are attributable to greater mean values in control women compared to handball players , whereas ballet dancers compared with both controls  and handball players  did not differ significantly. Furthermore, there was no significant difference between handball players and ballet dancers with respect to years of training, but compared to the handball players, the ballet dancers started training significantly earlier  = 7.69, p = 0.012).Demographic, behavioural, and global brain measures of the ballet dancers, handball players, and control women are summarised in F = 11.55, p < 0.001) and therefore their body mass index (BMI) is significantly lower than the one of the handball players and the controls  = 9.02, p = 0.001). In contrast, handball players showed no significant difference with respect to the BMI compared to control women (p = 0.646)  .M1/R of the ballet dancers (p = 0.020) and HANDS1/R of the controls (p = 0.003). The results of the rmMANOVAs derived from the relative GM volumes  were not different from those derived from the absolute GM volumes and therefore only the results of the absolute GM volumes analyses are reported. Furthermore, given the lower BMI values of the ballet dancers compared to the other two groups, we also controlled for the BMI in an additional analysis, and since there was no single statistically significant effect of any factor in which the BMI is integrated, we did not include the BMI as a covariate in our statistical models (neither in GM nor in FA/RD/AD rmMANOVAs) in order to preserve statistical power. Other significant main effects or interactions than those relevant for our hypotheses will be reported in Results as they might be of some interest for future investigations, but they will not be discussed further.All ROI GM volume data were approximately normally distributed except FOOTF = 16.51, p = 0.001, and ηp2 = 0.452; 3 groups: F = 21.73, p < 0.001, and ηp2 = 0.346) showing increased GM volume in S1 compared with M1, the 2-group rmMANOVA revealed the predicted interaction of GROUP x  BODYPART  = 5.27, p = 0.033, and ηp2 = 0.208). This interaction indicated increased GM volume in the feet representations of ballet dancers compared to handball players, whereas handball players showed increased GM volume in the representations of the hands compared with ballet dancers. With respect to the 3-group rmMANOVA including the control group the predicted interaction of GROUP x BODYPART was shown only with a trend towards significance  = 2.74, p = 0.077, and ηp2 = 0.118) (Beside the main effect of MODALITY (2 groups: = 0.118) , Table 3F = 7.11, p = 0.015, and ηp2 = 0.262) and with a trend towards significance as including the control group  = 2.85, p = 0.069, and ηp2 = 0.122), showing increased GM volume in the left hemisphere in handball players compared with ballet dancers , whereas right-hemispheric GM volume was increased in ballet dancers compared with handball players .Another significant group-specific interaction was also found between the factors GROUP x HEMISPHERE  = 8.48, p = 0.009, and ηp2 = 0.298; F = 9.05, p = 0.004, and ηp2 = 0.181) showing that GM volume was increased in the right hand areas compared with the left hand areas, whereas GM volume in the left foot areas was increased compared with the right foot areas.A further significant but not group-specific interaction was found for the factors HEMISPHERE x BODYPART (t-tests for independent samples are summarised in M1/R (t(20) = 3.66, p = 0.016, and d = 1.64) and FOOTS1/R (t(20) = 3.17, p = 0.020, and d = 1.42) is increased in ballet dancers compared with handball players. This supports the predicted interaction of GROUP x BODYPART in the sense that GM volume is increased in the feet representations of ballet dancers compared with handball players, but statistical significance was only reached for the right but not the left foot area, which in turn is in line with the interaction found between GROUP x HEMISPHERE, which showed that ballet dancers compared with handball players have increased GM volume in the right-hemispheric ROIs. As can be seen in M1/L and HANDS1/R, nevertheless support the interaction because the feet representations showed with large effect sizes increased GM volume in ballet dancers compared with handball players, whereas GM volume was increased in the hand areas in handball players compared with ballet dancers.The findings of the additionally conducted S1/R correlated positively with the number of years of training  and that of FOOTM1/R correlated inversely with the age at training commencement . No further statistically significant correlations were found.The mean GM volumes of each ROI were then correlated with age of training commencement and with the number of years of training within each sports group separately. In handball players, the GM volume of HANDThe ROIs used for GM volume extraction and fibre tractography are presented in Figures All ROI FA data was approximately normally distributed. The results of the rmMANOVA derived from the relative FA values  were not different from those derived from the absolute FA values and therefore only the absolute FA values are reported. Again, other significant main effects or interactions than those relevant for our hypotheses will be reported as they might be of some interest for future investigations but they will not be discussed further.F = 81.70, p < 0.001, and ηp2 = 0.803 and F = 112.11, p < 0.001, and ηp2 = 0.732, resp.) revealing decreased FA in S1 compared with M1, we found a significant main effect of the factor GROUP  = 26.91, p < 0.001, and ηp2 = 0.574 and F = 9.81, p < 0.001, and ηp2 = 0.324, resp.) with decreased FA in ballet dancers compared to handball players. The follow-up post hoc comparisons with respect to the 3-group analysis revealed decreased FA in ballet dancers both compared to handball players (p < 0.001) and controls (p = 0.018), whereas handball players showed only marginally increased FA compared to controls (p = 0.077).Beside a significant main effect of the factor MODALITY  = 16.66, p = 0.001, and ηp2 = 0.454 and F = 7.74, p = 0.001, and ηp2 = 0.274, resp.)  , Table 4F = 3.32, p = 0.084, and ηp2 = 0.142) nor for the 3 groups  = 2.34, p = 0.109, and ηp2 = 0.102) rmMANOVA. The RD analysis, however, revealed a significant interaction of GROUP x BODYPART  = 24.45, p < 0.001, and ηp2 = 0.550 and F = 8.09, p = 0.001, and ηp2 = 0.283, resp.), showing, contrary to FA, increased RD in the fibres connecting the foot areas in ballet dancers compared to handball players (and controls) but, as in FA, decreased RD in the fibres connecting the hand areas in ballet dancers compared to handball players (and controls). However, considering the differences within the groups, the ballet dancers showed higher RD in the fibres connecting the foot compared to their hand areas, whereas handball players showed higher RD in the fibres connecting the hand compared to their foot areas, where both correspond to the opposite directions of FA  = 87.96, p < 0.001, and ηp2 = 0.815 and F = 21.94, p < 0.001, and ηp2 = 0.517, resp.) revealing decreased FA both in the part of the CST connecting left- and right-hemispheric ROIs in ballet dancers compared to handball players (and controls); whereas for handball players FA is decreased in the part of the CST connecting the right- compared to their left-hemispheric ROIs, FA in ballet dancers (and controls) is lower in the part of the CST connecting the left- compared to their right-hemispheric ROIs.A further significant group-specific interaction was found in GROUP x HEMISPHERE  showed statistically significantly decreased FA values with large effect sizes in ballet dancers compared with handball players  showing significantly increased RD in ballet dancers compared to handball players and one concerns the hand area (HANDM1/R) with significantly increased RD in handball players compared to ballet dancers .For reasons of clarity and comprehension the Pearson correlations used to associate the GM and FA findings were conducted with only four instead of the initial eight ROIs. The ROIs were averaged with respect to the hemispheres because a significant main effect for the factor MODALITY was found, whereas, for the factor HEMISPHERE, this was not the case  and between GM-FOOTM1/R+L and FA-HANDS1/R+L .In ballet dancers, the following associations were significant or showed a trend towards significance, respectively: between GM-HANDM1/R+L and FA-HANDS1/R+L , GM-HANDM1/R+L and FA-FOOTM1/R+L , and GM-HANDM1/R+L and FA-FOOTS1/R+L  as well as between GM-HANDS1/R+L and FA-HANDS1/R+L .In handball players, the following associations were significant or showed a trend towards significance, respectively: between GM-HANDS1/R and the number of years of training suggesting that the GM volume in the hand area is enhanced with increasing years of training. This double dissociation is additionally supported by the differences in mean GM volume, for which handball players showed increased volume in three out of the four hand areas investigated (M1/S1 and left/right), whereas ballet dancers showed increased GM volume in three out of the four foot areas investigated. Indeed, not all of these differences in mean GM volume reached statistical significance, but all showed medium to large effect sizes, which leads to the assumption that a larger sample size would cause these results to reach statistical significance.As predicted, we found structural brain differences in the a priori defined brain regions between professional handball players and ballet dancers. The main result can be considered in the fact that GM volume in the hand representations is increased in handball players compared with ballet dancers, whereas GM volume in the foot representations is increased in ballet dancers compared with handball players. However, as including the control group, this interaction was only shown with a trend towards significance. The larger GM volume in the hand area of the handball players is supported by their positive correlation between GM volume in HANDWith respect to FA, the hypothesis was not answered as clearly. There is indeed a significant interaction between the factors GROUP x BODYPART, but ballet dancers showed decreased FA in both the fibres connecting the foot and hand areas compared to handball players. The fact that ballet dancers showed lower FA in the fibres connecting the foot areas compared to their hand areas, whereas handball players showed lower FA in the fibres connecting the hand areas compared to their foot areas, nevertheless strongly supports our hypothesised interaction of GROUP x BODYPART. Moreover, given that the significant interaction of GROUP x BODYPART in RD revealed exactly the opposite alterations compared with the interaction found in FA , it provides evidence that the reduced FA is driven by increased RD suggesting changes in myelinisation rather than changes in the axonal membrane .The findings in the GM volume, which was increased in the hand areas in handball players and increased in the foot areas in ballet dancers (interaction GROUP x BODYPART), suggest that training-induced neuroplastic adaptations are actually sport-specific rather than just sport-general. The results found as predicted are astonishing considering the fact that although the demands on the feet/legs are stronger in ballet dancers and the demands on the hands/arms are stronger in handball players, both sports need the upper and lower extremities intensively. Our results strongly suggest that brain structures differ in accordance with the demands and skills needed for a particular sport, although the two groups of athletes do not differ at all in their sportive experience and training intensity.As already mentioned, there are only three studies we are aware of comparing two groups of athletes , 17, 20.Increased GM volume in the hand area of handball players compared with ballet dancers is supported by another study, of course using the same sample of handball players, which revealed increased GM volume in the bilateral M1 and S1 hand representation when professional female handball players were compared with control women . A furthThe increased GM volume in the cortical representation of the foot area of ballet dancers compared with handball players and control women shows that training-induced structural adaptations are not restricted to the representation of the hand. To the best of our knowledge, we are not aware of any study that investigated the long-term impact of somatosensory-motor training of feet and legs. However, there are findings that can be related to our results. Liepert and colleagues  showed tThe interaction of GROUP x BODYPART of FA values was statistically significant but did not directly show the hypothesis-conform pattern of differences . Instead, ballet dancers showed decreased FA in both the part of the CST connecting the foot area and the one connecting the hand area compared with handball players and control women. Since in previous studies training-induced neuroplastic adaptations were observed in both directions (decreases and increases) and not only in WM but also in GM (for an overview see Table 1 of ), it remIn line with the assumption of reduced FA as a sign of training-related neuroplastic adaptations are the findings of the former ballet study of our group, in which the same ballet dancers showed reduced FA values in the premotor cortex near the primary motor cortex when compared with nonathletes . FurtherIn the field of functional neuroplastic adaptations however, it is accepted that specific skills in a domain are associated with reduced neuronal activity in brain regions involved in the control of the specific expertise , 54–56. A further explanation for the contradictory findings with respect to the direction of the adaptations (decreases or increases) might be related to the training phase in the sense that anatomical alterations in the form of increases take place in a rather early phase of training, whereas in later training stages no further increases or even decreases occur . In one M1/R) was revealed within the handball players , a correlation also found across both groups . Moreover, age of training onset correlated positively with FA in FOOTM1/L  and FOOTS1/L , respectively, whereas RD within these ROIs was inversely related to age of training onset . Therefore, these correlations only provide weak evidence for the idea that age of training onset is an important factor in order to explain the neuroplastic alterations observed in the ballet dancers and handball players of the current study.A third possibility might be rooted in interactional effects between the elements of a skill and the resulting anatomical adaptations. It is conceivable that the learning and training of a particular skill are associated with anatomical adaptations, irrespective of whether GM volume and FA increases or decreases occur, whereas the training of other skills might evoke no anatomical adaptations at all . The undFinally, the neuroplastic adaptations might also be prone to specific biological circumstances such as the genetic background or the eating behaviour that might interact with brain developmental processes . ParticuPotential reasons for the inconsistent FA findings can be numerous and are still not investigated at all. Due to the fact that FA is the ratio between AD and RD, high FA values reflect stronger AD along the fibres. Reduced FA can reflect increased RD, decreased AD, or a mixture of both. However, reduced FA can also be observed if different fibres cross, bend, and/or twist within a voxel. This is because the classical DTI tensor model can measure only one fibre direction per voxel. Diffusion spectrum imaging (DSI) might help disentangling whether there are indeed reduced FA values in a voxel or whether different fibres cross, bend, and/or twist within that voxel . HoweverThe aim of the analysis of associations between the two morphometric measures investigated was to test whether adaptations in GM and FA are related to each other or whether they are independent of each other . These aIn order to make inferences about possible physiological consequences of cellular alterations, it is necessary to know what kind of microstructural cellular mechanisms underlies the macroscopic changes. However, by using MRI, structural neuroplastic alterations can only be measured at the macroscopic scale and therefore the underlying microscopic cellular events of these changes are not clarified yet. Nevertheless, conceivable microstructural mechanisms have been proposed, that is, an increase in cell size, genesis of new synapses, genesis of glial or even neural cells, or changes in spine density, blood flow, interstitial fluid, or even angiogenesis , 61. YetThe fact that our results suggest sport-/skill-specific rather than just expertise-general neural adaptations as well as the fact that not only the hand but also the foot representations can be increased could probably play a role in contributing to the development of training-supportive methods for professional athletes. The aforementioned results of the studies conducted by Granert , Langer The mental imagination of motoric movements, called motor imagery (MI) , could bSeveral limitations of the present study are worth mentioning. First, the findings of the present study should not be considered to represent a fully independent replication of the findings of our two already published studies , 19 due 2 . Even though the calculation of the BMI does not distinguish between fat and muscle tissues and its relevance and interpretability when applied to athletes remain subject of dispute, a low BMI may indicate some form of malnutrition. Indeed, there is some evidence in connection with restrictive anorexia nervosa that malnutrition may lead to a reduction of GM volume in the brain. However, the findings were restricted to certain brain areas such as the anterior cingulate cortex, the frontal operculum, and temporoparietal regions [Last, a potentially critical aspect to address is the observed statistically significant difference between the two sports groups with regard to height, weight, and BMI. Last, ballet dancers showed considerably lower height, weight, and BMI as compared to handball players and control women, whereby 6 of the 10 ballet dancers would be considered slightly underweighted with BMIs below 18.5 kg/m regions . None ofAs predicted, sport-specific rather than sport-general adaptations in the M1 and S1 representation of the hand and feet were found between professional handball players and ballet dancers. The main GM volume finding is an interaction between the factors GROUP x BODYPART that revealed increased GM volume in the feet representations of ballet dancers compared with handball players, whereas handball players showed increased GM volume in the representations of the hands compared with ballet dancers. Furthermore, a statistically significant GROUP x BODYPART interaction was found for FA, but compared to handball players, ballet dancers showed decreased FA in both the fibres connecting the foot and hand areas. Nevertheless, there is an interaction in line with our hypothesis that ballet dancers showed lower FA in the fibres connecting the foot compared to their hand areas, whereas handball players showed lower FA in the fibres connecting the hand compared to their foot areas.Our results suggest that brain structures differ in accordance with the demands and skills needed for a sport and therefore indeed speak for sport-specific rather than just sport-general neuroplastic adaptations. However, longitudinal studies are needed in order to unequivocally track down whether the observed structural alterations between handball players and ballet dancers are driven by nurture (training-induced neuroplasticity) or by nature (genetic predisposition) or potentially driven by interactions between both.