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The EDIT Platform for Cybertaxonomy is a collection of open source tools and services which together cover all aspects of the workflow of the workflow in biology for describing, classifying and naming groups of organisms. The workflow is grouped into the following areas: taxonomic editing; publishing of edited data; data storage and exchange; collections and specimens; descriptions; fieldwork; literature; and geography. At the heart of the Cybertaxonomy platform is the Common Data Model (CDM), a repository for every conceivable type of data produced by taxonomists in the course of their work, and the backend for most EDIT components.
Platform Components
The main Cybertaxonomy platform components are listed below.
Further Components
- Specimen Search Portal
- Geo Tools: Map Services and Map Viewer
- Xper2
Reference Projects
Reference projects using the EDIT Platform: https://cybertaxonomy.eu/references
Get Started
If you want to try the EDIT Platform or contribute as a developer please contact email@example.com


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Availability : 0
Product Code : DCOW
Weight : 7.00kg
Super comfy, this chair will make you want to sit back, relax and let the world wonder by!
Nothing beats the feeling of sitting out on your boat taking in the sun and enjoying your surroundings, except that is, possibly doing exactly the same with added friends.
At Marine Teak we have lovingly assembled a collection of luxury accessories to compliment your boat and no more is this in evidence than our stunning Director's Chair.
The unique design is born from beauty yet built for durability. The knurled base stands give a much larger contact area than traditional feet resulting in incredible stability. The teak itself comes from the centre of the trunk, far denser and stronger than the outer sections often used in cheaper products.
The workmanship is exquisite, from the hinged fold down arms to the stainless steel stay's, every part of this chair is of the highest quality.
The quality doesn't finish with the frame either. High quality, hard wearing soft and comfortable, Sunbrella fabrics have been selected for the fully cushioned seat base and backrest, that as you would expect from a product of this calibre are extremely weather resistant and, should it ever be necessary, can be easily removed for washing. While they are off if you fancy a change, full sets of interchangeable covers are also available in one of five fabulous colours.
When those friends do pop aboard you will be safe in the knowledge that not only do you have the seats to make them comfortable, with their generous size of 490mm x 460mm 960mm but you know that those seats will complement the quality of your boat.
When your guests have left, the chair can be folded down to a diminutive 20cm x 46cm x 65cm, making it extremely easy to store. In fact about the only thing smaller than it is the tiny introductory price.
Whether as supplementary seating in a traditional cockpit or turning a sports fisher into a chic outdoor saloon for Al fresco dining around a Marine Teak table, these chairs represent incredible value at just £259 each.
Open Size:-
55cm x 46cm x 96cm
Folded Size:-
20cm x 46cm x 65.6cm
Please note: If you are outside Europe, please contact us prior to ordering as this item is excluded from the £25 international delivery charge - however, in many cases we can still deliver but there may be a slight increase in the cost. Please contact for details.
Love the stripes, they give our boat a very nautic feel. The chairs are very sturdy and solid. Your customer service is the best I have come across. Thank you./Carrie Birmingham
Very quick delivery. The chairs are fantastic. Nice and wide, comfortable, easy to collapse down for storage. The sunbrella cushions make them so easy to keep clean too. Very happy with my purchase..Colin UK
Just bought 4 of these for our garden parties, they look amazing.Elaine Johnstone Australia
These are so comfortable and look stunning. Being teak they match our cockpit table perfectly and have really transformed our boat. Fantastic quality and great value, would thoroughly recommend them to anyone.Ian UK
Ordered and delivered within 24 hours !! Perfect for our garden parties. Thanks !!Matt French Manchester UK
I bought 4 of these chairs and use them so much. They are very comfortable. Great value as they are solid teak.Danny Thompson IOM
Comfortable, easy to use and folds down to a nice size for storage. Looks great and is fantastic value for money.Steve Uk
I've just bought 2 of these chairs and received them them next day - quick delivery !! The chairs are very well built and I love the choice of colours for the cushions. The Sunbrella fabric makes them very easy to keep clean too.Cheryl Yorkshire
Bought three of these for our motorhome. Superb quality and fold away easily which makes them simple to store. The Cadet Grey is a lovely fresh clean colour,Virgina Alexander York
Ordered four for our boat, however upon arrival and seeing the quality we have decided to keep these ones at home in our garden. We have now purchased another 4 for the boat. Can recommend these chairs enough.L & G Griffith London
Fantastic build quality. The Taupe is a perfect match for our boat covers..D Berk UK

subset: commoncrawl


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Rarely has a vice presidential debate been as crucial as tonight's faceoff between Vice President Biden and Rep. Paul Ryan will be. After Mitt Romney's victory over President Obama in Denver last week, the exchange will arrive at a fluid and potentially pivotal moment in the campaign.
For the Obama team, tonight will offer an opportunity to short-circuit the advances Romney has made since the first presidential debate. For the GOP, Ryan will have a chance to piggyback on Romney's performance and solidify the gains their ticket has made in recent days.
The stakes are also higher than usual because the participants have a standing beyond their roles as running mates. They are real players, not potted plants or a sideshow to the main event.
Biden is vice president and therefore fully accountable for what has gone right and wrong on Obama's watch. He is a central player in the administration who has not shirked from offering the president unvarnished advice. He also speaks with the credibility of someone who has been in public life for four decades, with wide experience in foreign and domestic policy.
Ryan, too, is more than just a vice presidential nominee plucked from obscurity to fill out a national ticket. The House Budget Committee chairman may have a limited public profile nationally, but he has served seven terms in Congress and, of far greater significance, his peers consider him the intellectual leader of the Republican Party for his work on the budget and the economy.
If you doubt that, recall this: Long before Romney was the GOP nominee, Obama was attacking Ryan and his fiscal blueprint, an early foreshadowing of the 2012 campaign that has come into clearer focus this fall.
Some vice presidential debates are mere entertainment relative to the overall race, enjoyable but incidental to the fundamentals of the campaign. That was certainly the case four years ago when the forum, which drew a huge audience, was all about Sarah Palin, whose candidacy had captured the imaginations of friends and foes alike.
But the outcome of that exchange -- a tie or modest victory for Palin in the eyes of many pundits and a win for Biden according to the public -- did nothing to shift a race that already had moved away from Sen. John McCain, R-Ariz., and safely toward Obama. Tonight's debate at Centre College in Danville, Ky., could be different.
National public polls show movement toward Romney since Denver. A Pew Research Center poll released Monday highlighted a big gain for Romney. Gallup began posting a sample of likely voters from its tracking poll and Tuesday's showed Romney leading 49 percent to 47 percent. Among registered voters, Obama was ahead 49 percent to 46 percent.
GOP enthusiasm is up, which is good news for Romney. But more evidence is needed to know how much the landscape in the battleground states has been changed by the debate. CNN released a poll of Ohio on Wednesday that showed two things: Romney has narrowed the gap there, but the president is still ahead among likely voters by 51 percent to 47 percent. Other battleground surveys are expected by week's end, and they should give a clearer picture of the state of play.
Romney advisers say the key battlegrounds are now within the margin of error, a significant shift from two weeks ago, when Obama led in Ohio, for example, by six to 10 points, depending on the survey. They are far more bullish today than they were a few weeks ago amid Romney's difficulties.
Obama advisers say they, too, have seen some movement toward Romney but make two points to counter what the Romney team is saying. In Ohio, for example, they say that they still believe the president holds a real lead and that they remain narrowly ahead in a number of other states.
They argue that the big margins of two weeks ago were always destined to tighten, given everything that is known about these states from past campaigns. The debates, they say, accelerated a process that was likely to happen sometime in October.
But from their research, the race has begun to settle down. Romney is not continuing to gain ground. "Romney has consolidated some of the gains he was going to get anyway," said White House senior adviser David Plouffe. "We weren't going to win battlegrounds by 10 points."
The campaigns aren't playing the expectations game ahead of this debate as vigorously as they did before the first presidential debate. Biden is knowledgeable and an experienced debater. Republicans expect he will give Ryan a tough exchange.
Ryan also is considered smart, substantive and authentic. Some Democrats regard him as a better communicator than Romney. They don't anticipate he will stumble.
Ryan has several possible weaknesses. He knows the budget to such a level of detail that he could fall into wonk-talk if he is not careful. What works on the House floor or in an inside-the-Beltway debate won't necessarily work with a television audience of 50 million or more. As one Republican noted, Ryan has to resist being chairman of the House Budget Committee tonight.
Nerves also could be an issue. Ryan has never debated on a stage this big. He has much at stake. Beyond this election, there is the question of his future as a national Republican leader -- a possible presidential candidate in 2016 if Romney loses.
Biden's potential weaknesses are well known. One is a propensity to be windy, although he was anything but that against Palin. He has a history of verbal gaffes, but mostly when he is unscripted or lets his guard down, which shouldn't be the case tonight. He could appear condescending or patronizing to his younger rival. He could be too aggressive. He also must defend Obama's record on the economy, which the president did not do effectively last week.
Ryan said this week that he expects Biden to be forceful today to make up the ground that Obama ceded to Romney last week. Biden will attempt to force Ryan to defend what the Obama campaign considers Romney's dishonest performance in Denver.
The vice president's attacks probably will focus on Ryan's budget, which Romney has embraced only in part, and he is likely to try to make Ryan the issue as much as Romney. Ryan's challenge will be to make an appealing case for his worldview while making clear that Romney is the head of the ticket and running on his own platform.
The next presidential debate will be held Tuesday at Hofstra University in New York, but what happens tonight in Kentucky is likely to have a big effect on how things look by the time Obama and Romney meet again.
Stakes high as running mate meets running mate
Rarely has a vice presidential debate been as crucial as tonight's faceoff between Vice President Biden and Rep. Paul Ryan will be. After Mitt Romney's victory over President Obama in Denver last week, the exchange will arrive at a fluid and potentially pivotal moment in the campaign.


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A's can't pick up Hammel after early O's attack
Right-hander allows five runs in his second start with Oakland
OAKLAND -- The A's spent Saturday afternoon partying like it's 1989, but lost much of the feel-good mojo quickly upon taking the field.
Playing in front of several members of the '89 World Series club, not to mention a sold-out crowd celebrating the 25th anniversary of the franchise's last championship, the 2014 A's exited the first inning down a quartet of runs and fell short in their comeback attempt in an 8-4 loss to the Orioles.
The Angels lost, too, keeping them 1 1/2 games back of Oakland for first place in the American League West.
But they're not going anywhere. That's why the A's braved a blockbuster and reeled in Jeff Samardzija and Jason Hammel from the Cubs two weeks ago.
Hammel, though, didn't offer much to revel over in his home debut for the A's, getting just six outs and allowing five runs before handing the ball over to a bullpen that surrendered three more.
The veteran righty, facing the O's for the first time since pitching for them from 2012-13, didn't even record one out before allowing a three-run homer to Adam Jones, who finished the night with a career-high-tying five RBIs.
Leadoff man Nick Markakis went 4-for-5, and No. 2 hitter Steve Pearce contributed a pair of doubles, giving Baltimore's first three hitters nine of the club's 13 hits.
The A's as a team had eight.
"I played with those guys for two years, so they know me pretty well, I know them," said Hammel, who gave up a second first-inning long ball to J.J. Hardy. "Just bad execution on my part. Bottom line is I have to do better.
"You like to show them what they're missing, but they got the best of me tonight. There was outstanding energy out there tonight with the celebration, a lot of fun, so it's disappointing to send them home with an L."
Chris Davis' RBI double in the third marked the end for Hammel, who has allowed eight runs (seven earned) in seven-plus innings spanning two starts since his trade from the Cubs.
Don't fret just yet, said Orioles manager Buck Showalter.
"Trust me, we had Ham -- he's good people and a good pitcher," Showalter said. "They made a good acquisition and they'll like him. We were just fortunate what mistakes he made. He's one of those guys you've got to get something early off of."
"I'm not pitching like myself right now," Hammel said. "I need to get back into what I do well, and that's fastball command and harnessing the slider."
The A's, once again, wouldn't go down without a fight, putting two men on base with two outs in the ninth, but there would be no walk-off homer like there was in Friday's thrilling opener.
"We always have that feeling," said Jed Lowrie, who contributed a two-run double in the fourth and also drove in a run in the sixth following Josh Donaldson's double. "That's what makes this team fun to be a part of. Doesn't always work out, but I think if we continue to have that fight, it puts us in the right mindset."
"That's an attribute that this team takes pride in," said A's manager Bob Melvin. "That no matter what happens early on, we're going to try to peck away a little bit and get the tying run at the plate."
Brandon Moss pulled into the team lead for homers with his 22nd in the third, a solo shot to right field off southpaw Wei-Yin Chen that got the A's on the board.
Baltimore plated two runs off Dan Otero in the fourth, courtesy of Jones' two-run base hit through the middle, and one more against a familiar face in Jim Johnson in the ninth.
Johnson served up a loud homer to ex-teammate Davis, his ERA moving to 6.25 since the Orioles packaged him to Oakland in the offseason.


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Former "Hills" star Jason Wahler was reportedly arrested for driving under the influence on Friday night – marking the sixth alleged drinking-related arrest for the 23-year-old reality star in the past few years.
According to People, Wahler was arrested at 10:54 PM while a driving a 2008 Chevy Tahoe in Newport Beach, Calif.
He was reportedly released on his own recognizance hours later.
Last week, Wahler was seen in a video that surfaced online being arrested by police in Mexico after allegedly getting into a fight in a nightclub in Cabo San Lucas on March 11.
In September, he was arrested in Yakima County, Wash., for alleged assault and a related drinking charge.
Other past run-ins with the law include receiving 30 days in jail for a drunken brawl in a Seattle hotel in 2007 and two months in jail for assaulting a tow-truck driver and city employee in Los Angeles in 2006.
Wahler, who previously dated Lauren Conrad, called off his engagement to college student Katja Decker-Sadowski last year.
When contacted by People, rep for the reality star could not be reached for comment.
Related Content from AccessHollywood.com:
VIEW THE PHOTOS: Stars Of 'The Hills'… Past & Present
VIEW THE PHOTOS: Lauren Conrad: From 'Hills' Queen To 'L.A.' Author!
PLAY IT NOW: Kristin Cavallari On Heidi Montag's Surgery & Shooting Season 6 Of 'The Hills'
PLAY IT NOW: Kristin Cavallari: 'Lots Of Drama' Coming Up On 'The Hills'
MORE ACCESS ON THESE TOPICS: Jason Wahler - The Hills - Lauren Conrad - Jail - TV


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Learn how to install, set up, and configure your DAQ, CompactRIO, or instrument control hardware and learn the basics of LabVIEW software.
Find technical documentation, including product manuals, getting started guides, and specifications, for NI products.
Ask questions, share answers, and learn with your peers in the NI Discussion Forums.
Find example code to get started quickly or add new functionality to your applications.
Use the Service Request Manager to open a new request or check your request status. Please note that a valid service contract may be required and options vary by country.
The mark LabWindows is used under a license from Microsoft Corporation. Windows is a registered trademark of Microsoft Corporation in the United States and other countries.


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OK, so its been sitting in my dock for a few months, teasing me to give it the benefit of the doubt.
Oh my, what a roller coaster! First we were all blown away by the look of it in pre release teaser films, then disappointed when it seemed to be a new version of iMovie, with no use to us professional editors, turning to pissed off when we realized that Apple had dumped a product, a wonderful perfect product, that we earned our living by, followed by the worries that come with that
"Can I learn Premier in time?"
"Is Avid still around?"
"Do I have to go PC?"
"Can I still use Final Cut 7?"
"Will they continue to support that?"
So then comes along a pithy update, and some of the fears begin to fade,… phew.. its all gonna be OK? They are gonna fix everything are they?
Yes we can now import old projects, and gone is some of the immediate iMovie nonsense.
So I dive in, feeling hopeful, positive and optimistic! Seeing as the guy died an all…
With some grungy old footage taken with the wonderful 8mm app for iPhone…
After some initial worries where I dont seem to be able to save a project anywhere other than Macintosh HD, (in fact no SAVE button at all,, WTF!!!) I cheat by moving the projects from some godawful directory… (I dunno something like My Final Cut Movies, and it insisting on calling everything "events". My fucking shooting days aren't fucking weddings and funerals you know, just shoots!!!) … I move the directory by hand, to an external LaCie disk. It works despite me deleting all the silly sub directories, I relaunch FCX.
Down to editing… And this is where the review really starts…
… no it doesn't.. its HORRIBLE; just awful, cant find anything, no effects as far as I can see, pre made titles, all the clips insist on sticking together, like its a editing program on my fucking iPhone…
IT IS AS BAD AS I THOUGHT.. no.. sorry MUCH MUCH WORSE:. I really cant be bothered to write any more, Im so depressed… Im doomed… doomed! Message to Apple, I'm sticking with Final Cut 7, lovely wonderful Final Cut 7… when that's completely out of date, or YOU guys put an update in the OS that means that it doesn't work anymore, then I'm off to become a painter, or a farmer, or something else where I can basically be alone, and not have to deal with fucking idiots… in fact my brand spanking new Mac Book Pro is looking a bit grumpy now… having just written about its maker like this… fucking shut up you piece of silver shit!
Steve Jobs…I wouldn't wish cancer on anyone, but I dunno, I would have died of embarrassment!


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Public pension funds are recovering from Wall Street crisis
NEA says Pew report distorts the real strength, durability of public pension funds
WASHINGTON - April 26, 2011 -
NEA President Dennis Van Roekel today urged elected officials and policymakers to make sure they have accurate and up-to-date information on the strength and viability of public employee pensions. Van Roekel said a report, "The Widening Gap: The Great Recession's Impact on State Pension and Retiree Health Care Costs," released today by the Pew Center on the States, may cause unnecessary alarm because the data do not reflect current market conditions.
New research by the National Conference on Public Employee Retirement Systems (NCPERS) paints a much different, much more accurate, and far more positive picture. Based on the most recently reported data, public funds had an average one-year return of 13.5 percent. Funds participating in the study reported a 20-year average of 8.2 percent.
"Despite a drop in asset levels, stemming from the devastating 2008 stock market crash, pension funds across the country are recovering," Van Roekel said. "The Pew report is based on the 2008 and 2009 period, following the stock market crash, and the condition of anyone's portfolio during that period would be dismal. The fact of the matter is that by the end of 2010, state and local government retirement systems were reporting strong investment returns, growing assets, and more than adequate funding levels to provide current and future public employees with the modest retirement benefits they were promised."
According to Van Roekel, the average pension benefit for educators is modest—approximately $21,000 a year. "I'm not an economist, but as a math teacher I do know numbers. Guaranteed pensions remain the most economical and efficient way to ensure that Americans who have worked all their lives remain financially secure and self-sufficient during their retirement years," Van Roekel said.
States and localities devote only a small percentage of their spending to pension funding. According to recent estimates by the National Association of State Retirement Administrators (NASRA), less than three percent of all state and local government spending was used to fund public pension benefits. Further, NASRA says this cost should be considered in the context of the well-documented economic benefits that pension benefits generate in every state in the nation.
In most cases, pension funding shortfalls are the result of the market crash. Although the report's snapshot of plan funding cannot be taken as representative of the medium- or long-term outlook for pension plans, Pew is quite right to note that some state governments created the problem by deliberately failing to fund their pension plans.
Van Roekel cautioned that elected officials and policymakers should make sure they are making decisions based on facts, not misinformation. "The truth is that public pension funds are not the cause of state budget crises—Wall Street greed is the real culprit," Van Roekel said.
The National Education Association is the nation's largest professional employee organization, representing
3.2 million elementary and secondary teachers, higher education faculty, education support professionals, school administrators, retired educators, and students preparing to become teachers.
CONTACT: René Carter 202-822-7494, email@example.com


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The European Commission has published a video-presentation on EU action to support its Outermost Regions (ORs): Martinique, Guadeloupe, French Guiana, Reunion Island, Saint-Martin, Madeira, the Azores and the Canary Islands.
"Being rich in biodiversity and cultural heritage, the unique geology and location of these regions provide Europe with opportunities to push back the boundaries of our knowledge, helping us to find new ways ahead to deal with the key challenges facing us such as globalization and climate change. The research itself and the data it throws off are shared, bringing forward not only new answers, but also strengthening ties between the cooperating regions and country," says the European Commission in its video.
It concludes: "Immense solar eruptions, micro organisms found in rain drops, from sun spots to spotted frog, to research into renewable resources of energy and the management of water resources, EU is helping Europe's outermost regions to turn topographical and geographical challenges into assets which can be an example to us all."
"The internationally recognized biodiversity of EU ORs, as well as Overseas Countries and Territories (OCTs) not only benefits local people and economies, but also enriches the EU with a unique cultural and natural heritage," affirms Dr Hans Friederich, IUCN Regional Director for Europe.
In 2011, IUCN released a dedicated report, which proposes recommendations to protect and sustainably manage the unique natural heritage of EU ORs and OCTs and calls for shared responsibility and increased collaboration between all involved.
With the support from the Government of France, the IUCN Programme on EU ORs and OCTs builds partnerships to meet biodiversity and climate change challenges in these territories. The Programme advances the implementation of the Message from Reunion Island – a series of concrete actions to protect biodiversity, economies and diverse ways of life of EU ORs and OCTs.


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Three groups of people - including life guards - patrolled Clarke Quay on New Year's Eve to ensure the safety of party-goers along the Singapore River.
Photo gallery: Extra security at Clarke Quay on New Year's Eve
- PublishedJan 2, 2013, 5:30 am SGT
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To start your free quote, tell us where you are traveling.
For 20 years, we have traveled the world with you, covering over nine billion miles together. And this year, we're still with you. As we celebrate 20 years of connecting you to the best trip insurance, we reflect on our past and look forward to the future. No matter where your next adventure takes you, we will help you find the right travel insurance.
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You should be sure you have chosen the right plan for your trip. If you're not, simply cancel it for a refund. Details subject to change by plan.
Travel insurance protects travelers in case of emergency or interruption of a trip.
You want peace of mind when you travel. With InsureMyTrip's quote process, you can research, compare and buy an affordable plan today. As the leader in trip insurance, we are a single site designed to help you compare benefits, get quotes, buy policies, and save from the top rated carriers. Please compare plans at different levels of coverage. Guard against cancellation of your flights, cruises, unexpected medical expenses, emergency evacuation, and lost luggage. Our licensed insurance agents provide service to assist you in finding the right coverage. Our Anytime Advocates help you if you have a claim and have helped put $1,000,000 of coverage back in travelers' pockets. Please research our plans using our 70,000+ travel insurance reviews to find the right coverage.
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Answer these questions to start. What pre-paid trip costs are you unwilling to lose? What unpredictable expenses would you not be able to cover? What reasons might cause you to cancel unexpectedly? There are different plans and options that allow you to cancel for any reason. There are plans that have better coverage for emergency evacuation and emergency medical treatment. Some plans cover you in case of terrorist activities and others have limited coverage. There are limits to each plan as to how much they cover for loss of personal belongings. Learn about the types of coverage, benefits, and limitations.
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Before hitting the road on your next domestic adventure, check our our guide to the current U.S. travel restrictions between states to ensure you know what to expect.Read More
Travel fraud is a real threat and travelers are often seen as attractive targets. Be aware of the latest tactics of scam artists to best protect yourself against falling for a trick.Read More
Preparation is an important part of any trip. While the contents of your suitcase will change, there are a few key documents you'll want to make sure are always with you.Read More


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Effect of assertive outreach after suicide attempt in the AID (assertive intervention for deliberate self harm) trial: randomised controlled trialBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4972 (Published 22 August 2012) Cite this as: BMJ 2012;345:e4972
- Britt Morthorst, research assistant1,
- Jesper Krogh, research assistant1,
- Annette Erlangsen, senior researcher12,
- Francisco Alberdi, chief psychiatrist1,
- Merete Nordentoft, professor1
- 1Research Unit, Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
- 2Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Correspondence to: B Morthorst britt.morthorst{at}regionh.dk
- Accepted 11 July 2012
Objective To assess whether an assertive outreach intervention after suicide attempt could reduce the frequency of subsequent suicidal acts, compared with standard treatment.
Design Randomised, parallel group, superiority trial with blinded outcome assessment.
Setting Outpatient intervention at one location at Copenhagen University Hospital, Denmark.
Participants Patients older than 12 years admitted to regional hospitals in Copenhagen with a suicide attempt within the past 14 days. We excluded patients diagnosed with schizophrenia spectrum disorders and patients living in institutions.
Intervention Case management through assertive outreach that provided crisis intervention and flexible problem solving. This approach incorporated motivational support and actively assisted patients to scheduled appointments to improve adherence with after-treatment as an add on to standard treatment.
Main outcome Repeated suicide attempt and death by suicide, recorded in medical records and death register at 1-year follow-up.
Results 243 patients were included. During 12 months of follow-up, 20/123 (16%) patients in the intervention group had been registered in hospital records with subsequent suicide attempt, compared with 13/120 (11%) in the control group (odds ratio 1.60, 95% confidence interval 0.76 to 3.38; P=0.22). By contrast, self reported data on new events showed 11/95 (12%) in the intervention group versus 13/74 (18%) in the control group (0.61, 0.26 to 1.46; P=0.27). By imputing missing data on the selfreported outcomes, we estimated 15/123 (12%) events in the intervention group and 23/120 (19%) in the control group (0.69, 0.34 to 1.43; P=0.32).
Conclusion Assertive outreach showed no significant effect on subsequent suicide attempt. The difference in rates of events between register data and self reported data could indicate detection bias.
Trial registration ClinicalTrials.gov NCT00700089.
Suicidal behaviour is a serious worldwide public health problem; a million suicides are estimated to occur each year.1 2 Attempted suicide is under recorded.3 4 Nevertheless, the number of non-fatal episodes is estimated to be 10 to 40 times higher than that of fatal episodes.1 5 Suicide attempts occur most frequently among young women6 and an increase in the rate of suicide attempt has been noted internationally, especially among women aged 15 to 24 years.7 8 9
Besides mental illness and substance abuse, previous suicide attempt is the most prominent predictor of subsequent suicidal behaviour.10 Median rates of repeated suicide attempt are 16% for non-fatal and 2% for fatal episodes within a year of the index attempt.11 12 A European multicentre study previously recorded repetition rates of up to 30% within the first year.13 Recent studies have presented similar repetition rates for adolescents.14 The first month after a suicide attempt carries an especially high risk of repetition.15 16
Results from randomised clinical trials of treatment after suicide attempt, synthesised in systematic reviews, are heterogeneous in interventions and effect.6 17 18 Reviews of psychosocial interventions, including a Cochrane publication and guidelines from the National Institute for Health and Clinical Excellence in England and Wales (NICE), have not found conclusive evidence on treatment strategies for this high risk group.17 19 20 21 22
Patients with suicidal behaviour have been characterised as difficult to engage in after-treatment.23 Various trials of interventions offering help after contact with emergency rooms have focused on treatment accessibility and adherence to after-treatment, to optimise the treatment chain for both adults and adolescents.18 24 25 17 19 20 21 22 To reduce the gap between treatment of suicide attempt and after-care, a specialised prevention team in Norway provided during a 23 year period a flexible, assertive, and individually shaped treatment to people who attempted suicide without severe mental illness.26 When it compared patients who received support from the prevention team with those who did not, the study found no significant difference in risk of repeating suicide at 12 months (adjusted odds ratio 0.86; 95% confidence interval 0.5 7 to 1.30). The study, however, did not have a randomised design and could therefore have been influenced by selection bias. A recent randomised trial27 evaluated the Norwegian model by offering six to eight assertive and motivational consultations, while a similar control group received standard care from a general practitioner. The study, which included 133 patients, found a significant difference in favour of the intervention compared with standard treatment with rates of repeat suicide attempt being 9% v 22%; P=0.04). However, the power of the study was limited. To confirm these promising findings, our objective was to replicate the study with higher power as a randomised, parallel group, superiority trial.
The aim of this study was to investigate whether an assertive outreach intervention assigned after suicide attempt could reduce the frequency of subsequent suicidal acts, compared with standard treatment.
The assertive intervention for deliberate self harm (AID) trial was designed as a pragmatic, randomised, parallel group, superiority trial with blinded outcome assessment. The trial protocol was approved by the local ethics committee (journal number KF-01 271146), the Danish Data Protection Agency (journal number 2011-41-6398), and registered at clinicalTrials.gov (identifier NCT00700089). It was undertaken at a single location at the Copenhagen University Hospital, Copenhagen, Denmark.
Participants were patients admitted after a suicide attempt to acute emergency units, intensive care units, paediatric units, and psychiatric emergency rooms in six regional hospitals in the catchment area of Copenhagen. We made referral agreements through personal meetings with units in charge of standard treatment provided to patients with suicide attempts. We distributed pocket sized laminated sheets with inclusion and exclusion criteria to doctors in somatic and psychiatric units. Children and adolescents were referred to the AID trial from the hospital conducting the trial and from other hospitals treating children, in addition to standard procedures for psychiatric consultation. General practitioners who contacted hospitals to refer possible patients with recent suicide attempt were also informed about the trial.
Inclusion criteria
We included male and female patients aged 12 years and older with a suicide attempt within the past 14 days who were able to read and understand the informed consent statement. We made one exception with regard to the age criteria; a female patient was included shortly before her twelfth birthday.
All the suicide attempts of included patients fulfilled the WHO definition: "An act with a non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that without intervention from others will cause self harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences."28 Patients presenting with self injuries, such as cutting, were only included if they also met the definition of non-habitual behaviour. This was verified for each single case through patients' self reports and medical records. Patients diagnosed with severe personality disorders, including eating disorders, were invited to join the study, as were patients with alcohol misuse or with no offer of subacute treatment meeting the need for suicide prevention.
Exclusion criteria
We excluded patients admitted to a psychiatric ward for more than 14 days after the index attempt. This enabled us to investigate the effect of the intervention for high risk patients in subacute phases. We also excluded patients who had been diagnosed with schizophrenia spectrum disorders (ICD-10: F20-29), severe depression (ICD-10: F32.2, F32.3, F33.2, and F33.3.), severe bipolar disorder (ICD 10: F30 and F31), and severe dementia (ICD 10: F0-9), because intensive outreach teams are already implemented as standard care for these patients in Denmark. Furthermore, patients with severe depression or bipolar disorder and suicidal behaviour would probably need inpatient care and would not be eligible for outpatient treatment. We also excluded patients who were receiving outreach services from social service agencies or living in institutions, to prevent mixing different effects and avoid confounders.29
Standard treatment
The standard treatment consisted of referral to a range of different treatment modalities, dependent on the diagnosis and the clinical and social conditions of the patient. While the patient was still being treated for the self injury, a routine psychiatric evaluation would often be used to determine whether he or she should be referred for further treatment—for example, general practitioner, psychological therapy, or treatment for alcohol abuse. In the standard treatment there was no procedure to ensure compliance with the recommended treatment. For the most part, the patients were responsible for contacting the treatment provider to which they were referred. As a part of the standard treatment, the Centre of Excellence in Suicide Prevention Copenhagen offered six to eight therapeutic sessions to patients who did not abuse substances and were not receiving other ongoing treatments. A psychologist provided these sessions as short term therapy with risk assessment tools from the Collaborative Assessment and Management of Suicidality (CAMS) approach.30 31 This option of after-treatment was available to patients in both groups. Pharmacological treatment of any kind was continued or prescribed in both groups when relevant.
The AID intervention was provided as case management with crisis intervention and flexible, problem solving, assertive outreach through motivational support and actively assisting patients to and from scheduled appointments, to improve compliance with after-treatment. The intervention represented eight to 20 flexible outreach consultations performed by specialised nurses (AID managers) over 6 months in addition to standard treatment. The first consultation was offered a few days after discharge and focused on acute prevention strategies, such as developing a crisis intervention plan in case of relapse. Subsequent consultations established a professional relationship, addressed problem solving strategies, and undertook specific actions. To ensure continuity, the same AID manager contacted the patient throughout the 6 months of the intervention. Motivation towards after-treatment was stressed as a core feature and referral was organised. Consultations were provided equally as home visits or meetings in cafes, as preferred, as well as meetings with healthcare, official, and social services to accommodate individual needs. The AID manager was responsible for maintaining contact, but the patient was asked to make contact between consultations if necessary. Telephone calls and text messages were frequently used to strengthen the alliance. The manager offered mediating family consultations to adolescents and their relatives, and suggested the involvement of social or professional networks irrespective of age. During relapse or stressful life events, frequency of contact was intensified, including availability of contact out usual hours to prevent subsequent suicidal behaviour. If the patient had severe suicidal impulses, the manager asked him or her to take a prepaid taxi to the psychiatric emergency room if all other items on the crisis intervention plan had failed in changing the impulses or providing relief of psychic pain. A minimum of four personal contacts was defined as adherence to the AID intervention; additional phone calls and text messages were not defined. Cafe visits did not count as crisis interventions. If, however, the patient revealed severe suicidal impulses during a cafe visit, the manager would usually prolong contact to cover decisions of crisis management.
Staff requirements
The intervention staff (AID managers) were highly qualified psychiatric nurses with specialised training in suicidology. Regular consultations were done with the supervising chief psychiatrist and research assistant to ensure adherence to the research protocol. The target for maximum caseload for each AID manager was 20 patients in active intervention treatment at any time. If a patient died by suicide, the AID manager assigned the patient would immediately be relieved from duty for a period of time.
We interviewed patients at baseline to obtain information on socio-demographic variables and method used for the index suicide attempt. The outcomes of interest were repeated suicide attempt and death by suicide with a follow-up period of one year after inclusion date. We obtained information on these events through ICD-10 diagnoses (recorded as part of standardised hospital registration procedure) and review of medical records. Additionally, we collected self reported data on events within the first year of follow-up, through telephone interviews with patients. Patients who could not be reached by phone after persistent attempts were contacted by regular mail.
An external medical evaluation committee conducted a blinded outcome assessment using medical records. Owing to the nature of the study design, the intervention staff were not blinded. The researcher conducting the analyses on self reported outcomes was also not blinded.
Statistical power
On the basis of previous studies,27 we estimated an expected repetition risk of 30% in the standard group and 15% in the intervention group within one year of the index attempt. With an α value of 0.05, we required 120 patients randomised to each treatment arm to reach a power of 80%.32
Computer randomisation was done by an independent research assistant at the Mental Health Centre Copenhagen, stratified by whether the patient had previously attempted suicide (first attempt v previous attempt), previous psychiatric contacts or hospitalisation (none v previous contacts), and alcohol consumption at time of suicide attempt (none v alcohol consumption). The AID managers were informed of the allocation by phone and the patients were immediately informed of the outcome. The randomisation procedure ensured adequate sequence generation and allocation concealment.
Statistics and data analysis
We assessed frequencies, means, and standard deviations of socio-demographic and patient characteristics and tested differences between groups with χ2 or independent sample t tests. We calculated the log odds of a patient having a recorded or self reported new suicide attempt in the 12 months following the index attempt. In subsequent planned analyses, we adjusted for possible baseline differences relevant for the primary outcome. All patients were included in the analysis regardless of subsequent adherence to treatment, according to the intention to treat principle. All statistical tests were two sided and P values less than 0.05 were considered statistically significant. We imputed missing values for the self reported outcome as a dependent variable using multiple imputations by applying a linear regression model with the following predictor variables: allocation, suicide attempt prior to index attempt, alcohol intoxication at index attempt, psychiatric contact prior to index attempt, unemployment, antidepressant medication, and discharge from a psychiatric hospital within the previous four weeks. The imputation was conducted using 100 imputations and 20 iterations. The pooled estimates from these imputations were subsequently used for analysis. The statistical software package SPSS version 19.0 was used for the analyses.
Ethical considerations
We obtained written consent from all participants after providing them with both oral and written information about the conditions of participating in scientific research in general and with specific details of the AID trial. Age specific consent forms were developed for children and adolescents. Written consent from both custody holders was required and obtained for children aged 11-14 years. Adolescents aged 15-17 years were allowed to decide and give written consent themselves as long as their parents were informed, according to the Danish Committee on Biomedical Research Ethics.
Between November 2007 and March 2010, 305 patients were invited to participate in the trial (figure 1⇓). During the 29 months, 243 patients (184 women; 76%) were included. The mean age was 31 years in the control group (standard deviation (SD) 12) and 31 years in the intervention group (SD 14; range 11-69 years). Of those included, 67 (28%) were aged 20 years or younger. The only differences between participants at baseline were that patients in the intervention group were more frequently being treated with antidepressants at inclusion (χ2 6.76, df 1, P=0.03) and more frequently used narcotics as method of suicide attempt, compared with controls (P=0.05) (table 1⇓). Self reported data on subsequent events were obtained from 169/243 patients (70%). Significantly more patients provided this information in the intervention group (95/123, 77%) than in the control group (74/120, 62%, χ2 7, df 1; P=0.01).
Service use in the intervention group
The service offered in the AID-intervention was flexible, with a median of 9 (interquartile range (IQR) 6-12) home consultations including cafe visits, 1 (0-3) attendances to healthcare services, 12 (7-21) phone calls to patients and relatives, and 2.5 (0-5) and 5 (0 to 8) phone calls to healthcare and social services, respectively. The median number of text messages sent was 17 (IQR 8 to 30). In total, 91 crisis interventions were provided. These interventions included phone calls when severe suicidal ideation or impulses were present and emergency calls when either somatic or psychiatric admission was requested. Five patients did not receive the allocated intervention because they withdrew from the study.
Primary outcome
During the 12 months' follow-up, we found that 20/123 (16%) patients in the intervention group had been registered in hospital records with subsequent attempts, compared with 13/120 (11%) in the control group (odds ratio (OR) 1.60, 95% confidence interval 0.76 to 3.38; P=0.22 (table 2⇓). Adjusting the primary analysis with the use of antidepressants at baseline did not markedly alter the results (1.67, 0.78 to 3.58; P=0.19). Our analysis suggested no association between antidepressants and allocation (P=0.48).
By contrast, self reported data on new events showed 11/95 (12%) in the intervention group versus 13/74 (18%) in the control group (OR 0.61, 95% confidence interval 0.26 to 1.46; P=0.27; table 2). Seven patients (four in the intervention group versus three in standard care) were identified with a subsequent suicide attempt in the hospital records although the patients themselves had reported none. Correspondingly, nine patients (one in the intervention group versus eight in standard care) themselves reported subsequent attempts that were not listed in the hospital records. Analysis of missing self reported data based on baseline information about relevant risk factors (sex, age, unemployment, suicide attempts prior to index attempt, prior psychiatric admission, and alcohol consumption at index attempt) assumed data were missing at random. By imputing missing data on the self reported outcome as described above we estimated 15/123 (12%) in the intervention group and 23/120 (19%) in the control group (OR=0.69, 95% confidence interval 0.34 to 1.43; P=0.32; table 2).
We identified two deaths due to causes other than suicide; one in the intervention group and one in the control group. One patient died by suicide in the intervention group within two weeks of the index attempt.
Combining the self reported outcome with the hospital records in post-hoc analyses did not markedly alter results (OR=0.97; 95% confidence interval 0.50 to 1.89; P=0.93).
Additional analyses using attendance to healthcare services as the outcome did not show more health care contacts by participants in the intervention compared with the standard group (OR=0.57 95% confidence interval 0.29 to 1.14; P=0.11). Similarly, attendance to social services was similar between in the two groups (1.01, 0.61 to 1.68; P=0.96).
Subgroup analysis
A separate subgroup analysis conducted by age group showed no impact of age on estimated effects of the intervention (table 2). Subgroup analyses by sex and by diagnoses of mild to moderate depression and personality disorders did not obtain differences in effects.
Principal findings
This pragmatic, randomised controlled clinical trial investigated the effect of assertive outreach as a preventive treatment strategy for patients with a recent suicide attempt. The trial did not find any significant difference in repetition rates between the group receiving the intervention and the group receiving standard treatment. We noted a difference between register data and self reported data for subsequent suicide attempts, especially in the control group. The AID trial has contributed to international research by investigating an assertive approach demanded by experts and clinicians.
Strengths and weaknesses of the trial
A strength of the trial was the randomised design and high methodological quality, associated with a low risk of bias.29 The robustness was increased by a relatively large sample size and use of detailed register data to ensure that no patients were lost to follow-up. The frequency of assertive consultations and service use suggest that patients accepted the experimental intervention by adhering to the approach. The study covered a heterogeneous population, including patients with alcohol and substance abuse problems, and those diagnosed with borderline personality disorder and various other diagnoses. Both these groups are at high risk,12 33 often with limited or already rejected treatment opportunities. The trial population was therefore similar to that seen in clinical reality, leading to high external validity of the study. Since patients diagnosed with schizophrenia spectrum disorders were excluded, the findings do not apply to these patients, but they do apply to other groups of high risk patients without psychosis.
The lack of a manual based approach for the AID intervention and the presence of various kinds of after-treatment modalities in both study groups makes replication less feasible and could affect the internal validity. Marked distinctions between the standard and intervention approaches were the assertiveness, the accessibility, and the active assistance of patients to scheduled appointments in the intervention group; these parts were all thought to be substantially relevant for this patient group.18 23 24 25 The standard treatment offered by the Centre of Excellence in Suicide Prevention Copenhagen improved during the study period and is judged to be after-treatment of good quality. As the AID intervention was an add-on, the standard treatment was also offered to patients in the intervention group, thus avoiding risk of bias. Although the study groups were located in different settings, contamination of standard treatment cannot be excluded. Different motivational factors might explain the lack of a difference between the groups in attendance of health and social services. During the study period, the Danish government's requirements for receiving sick leave benefits included mandatory frequent contact with social services; if citizens did not attend scheduled appointments, they risked losing their sick leave benefits. Also, social services often require medical documentation in order to issue sick leave benefits. Figures of attendance to health and social services in the control group do not show whether patients were adherent to service requirements.
The significantly higher proportion of patients prescribed antidepressants at baseline in the intervention group could constitute a source of bias. These patients might represent a group with more severe mental illness who might also be more difficult to prevent from subsequent suicidal behaviour.18 On the other hand, patients already receiving drug treatment might, arguably, be less depressed than those not receiving pharmacotherapy.18 20 However, the analysis adjusting for this potential confounder found no indication of bias.
The relatively wide age range of the study population, which included teenagers and older people as well as people of both sexes, could be considered a potential limitation owing to the varied needs and help seeking behaviours of different groups. However, our subgroup analyses showed no effect of age or sex on the findings. The recorded rate of subsequent suicide attempts among males was slightly higher in the intervention group than in the standard group, which might give rise to speculation that males in the standard group were less inclined to seek help, leading to detection bias. However, the difference in rates between the groups was not significant.
We expected that adherence to the AID intervention would reduce subsequent suicide attempts. However, we also expected that the intervention would encourage participants to seek contact more frequently, which could have increased the likelihood that subsequent attempts were reported. The higher repetition rate shown in the hospital records might suggest that patients in the intervention arm, after subsequent attempts, called the AID manager, who then provided emergency arrangements. The weakening of differences in effect when self reported information was added to the analysis adds to this argument.10
The power calculation, in which we estimated a repetition risk of 30% in the standard group and 15% in the intervention group, could be judged to be too optimistic. The calculation relied on rates recorded in past European studies13 34 but might not have been powered to detect smaller differences such as those present in this trial.
There was disagreement between the two data sources over the number of suicide attempts. The clinical decision to classify a self inflicted episode as a suicide attempt corresponding to a diagnosis in hospital records is often not consistent. Also, in the acute phase of treating the trauma, diagnoses from emergency departments do not always reflect the suicidal dimension of the event,3 unless the risk of suicide is ongoing. The WHO definition of suicide attempt used in this trial also leaves room for interpretation; although a blinded external evaluation committee examined doubtful cases in detail, a small number of false positives was unavoidable, especially since the medical records in some cases provided limited information. The dissonance in number of suicide attempts between the two data sources could also have been due to differences between the groups in the participants' perception of their own need or attitudinal barriers—for example, the wish to handle problems alone, which is related to lower tendency for help seeking behaviours.35 36 37 Furthermore, some patients might not be completely truthful about subsequent suicide attempts in order to perform well when interviewed by the researcher, hence a risk of performance bias. On the other hand, patients who reported subsequent attempts but had no hospital record of such an event might have preferred to avoid hospital contact, because they feared being registered and potentially stigmatised later on. These factors reflect a risk in this trial of detection bias related to both underestimation and overestimation.
The multiple imputations indicated a potential underestimation based on self reported data.29 However, given that suicidal patients tend to display a lack of treatment seeking behaviour, self reported data might actually have a higher validity than register data.
Restrictions by the Danish Data Protection Agency did not allow analysis of information on patients who refused to participate in the trial. Because the inclusion criteria were pragmatic, we did not expect this to affect the external validity.
Previous studies have recommended a structured risk assessment as an important tool in suicide prevention.22 Although suicidal behaviour was routinely addressed as a pivotal point of all consultations in the AID intervention, no formal risk assessment tool was used besides the development of crisis intervention plans and individual psychoeducation.
Comparison with other studies
The result of the present trial are similar to those presented in reviews of psychosocial interventions in general.18 19 20 However, a study of a similar intervention by Hvid and colleagues did find an effect.27 The differences in baseline characteristics between that trial and the AID trial suggest that our study included more patients with previous suicide attempts and former psychiatric contacts. The study populations might have differed, therefore, in severity of mental illness. However, Hvid and colleagues did not provide information on diagnosis, and data on service use were only provided for the intervention group. Interestingly, both trials used same inclusion and exclusion criteria and were conducted within a few years and a radius of 5 km. The most likely explanation for the difference in effects seems to be type one error, or that the standard treatment offered in the previous study was less intensive. Standard treatment in the previous study mainly consisted of standard care in general practice, whereas the current study was able to offer an enhanced treatment through the Centre of Excellence during the AID trial.
Baseline characteristics of the current sample resembled populations in international studies; for instance, three quarters of those who attempted suicide were women,6 one quarter were of younger age (<20 years),8 9 38 and overdose was the most frequent method.6 16 Based on post-hoc analysis, the combined repetition rates based on medical records and self reported data were estimated to be 17% for the intervention group and 18 % in the standard, respectively, which corresponded to repetition rates previously outlined in international reviews.10 11 12
Possible explanations and implications for clinicians and policymakers
Although experts, clinicians, and patients have called for an assertive approach to suicide prevention, we did not find evidence to recommend such a strategy. However, the complexity of suicidal behaviour might not be addressed adequately by accompanying patients to after-treatment if waiting lists are extensive, or if the treatment modalities are not evidence-based. By comparison with other settings, the standard treatment in our trial was of good quality, and this could affect the external validity. However, the repetition rate among recipients of standard treatment was still very high. We do not believe, therefore, that the threshold for improvements has been reached. It would have been appropriate and interesting to rate patients on relevant suicidal scales (for example, for depressive symptoms, substance abuse, and self efficacy) at baseline and follow-up, to detect any difference in secondary outcomes in relation to treatment modalities.
Extensive information is available on risk factors for suicidal behaviour,6 10 39 but less is known about recommendations for psychosocial treatment.19 20 Evidence of benefit has been shown for cognitive behaviour therapy21 22 and for psychosocial treatment within a family context for adolescents.40 However, this evidence relates to specific subgroups and has yet to be replicated in heterogeneous populations.
A remarkable relative difference was noted between the number of registered and self reported repeated suicide attempts among patients in the standard treatment. Suicide attempts are probably under recorded in general.1 5 6 However, it is worrisome that these people did not seek help despite being enrolled in an ongoing treatment programme. The estimate of multiple imputations on self reported data suggested that there could be even more patients with subsequent unrecorded events in both groups. The long term consequences of untreated deliberate self harm are unknown, but are certainly a potential risk factor.
Patients attempting suicide constitute a heterogeneous group, differing in age, life conditions, and risk factors. Prevention strategies targeting repeated suicide attempts need to address most of the raised risk factors by providing crisis intervention, being assertive and accessible, and at the same time offering individually shaped support. The AID intervention aimed to incorporate all these essential elements and yet failed to reduce the repetition frequency in a large, representative sample. Future research could target subgroups with even more specialised therapeutic interventions, such as specialised cognitive behavioural therapy, or could focus on primary prevention strategies addressing risk and vulnerability before the first suicide attempt.
What is already known on this topic
Suicide attempt is often associated with subsequent suicidal behaviour, but patients can be difficult to engage in after-treatment
A previous study with limited power suggested that assertive and motivational consultations could reduce the rate of repeated suicide attempts
What this study adds
This randomised clinical trial did not find evidence to recommend an assertive intervention over standard care for patients after suicide attempt
Patients allocated to the intervention were more likely than controls to be hospitalised and treated for subsequent suicide attempts
Patients were compliant with the intervention
Cite this as: BMJ 2012;345:e4972
We thank all included patients and relatives, intervention staff Agnete Birktoft and Hanne Frandsen, all collaborating partners in intensive units both somatic and psychiatric, Centre of Excellency in Suicide Prevention, social services, external psychiatrists, and psychologists. We thank the investigators Hvid and Wang for their collaboration.
Contributors: MN was primary investigator. BM and MN developed the research protocol, designed the study, acquired funding, carried out the intervention, and gathered data. FA was administrative collaborator and consulting physician for the research assistant. FA, AE, and MN were the blinded external evaluation committee. BM and JK constructed the database and conducted the statistical analysis. All authors contributed to writing and revising the manuscript. BM and MN are guarantors.
Funding: The study received funding from the Ministry of Health and Internal Affairs, Denmark, the National Board of Social Services, an independent subdivision of The Ministry of Social Affairs and Integration, TrygFonden, and Aase og Ejnar Danielsens Foundation.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: the study received funding from the Ministry of Health and Internal Affairs, Denmark, the National Board of Social Services, an independent subdivision of The Ministry of Social Affairs and Integration, TrygFonden, and Aase og Ejnar Danielsens Foundation; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: The trial was approved by the Danish Ethic Committee (journal number KF-01 271146) and by the Danish Data Protection Agency (journal number 2011-41-6398). All participating patients gave written informed consent.
Data sharing: No additional data available.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.


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Understanding Business Services
Like Kevin Costner's character, Ray Kinsella, in the movie Field of Dreams 1, maybe you have been hearing voices whispering: "If you build it, [they] will come." When Ray heard the voice, he was inspired to build a baseball field in an Iowa cornfield. With all of the voices sounding out about Web Services, you may be thinking about building services and using service-oriented architectures2. Just as the need seemed unclear at first to Ray, a service-oriented platform running business services can deliver significant benefits to you and your organization over time.
This article will describe the key characteristics of business services and the value they provide. The following outline is a roadmap for how we'll cover the topic:
- What Is a Business Service?
- A Business Service Models the Business Domain
- A Business Service Is Interoperable
- A Business Service Is Accessed by Its Interface
- Summary
The article will assume a basic understanding of service-oriented architecture. There are additional resources at the end to dive further into this topic.
What Is a Business Service?
Simply stated, a business service is an interoperable software component that provides a business function. Business services are deployed on service-oriented architectures that expose them to heterogeneous clients through common protocols such as HTTP and self-describing payload formats represented by various XML vocabularies.
Business services provide the potential for a level of re-use beyond what has been accomplished through other distributed component technologies. The basic definition of a service is a component that has a network addressable interface. Prior technologies had tight coupling between the client and service in terms of language, runtime classes, and runtime environment. Services were only usable by homogeneous clients. Today's service-oriented architectures reduce the coupling between clients and services by using standard protocols and payload formats and make them available to heterogeneous clients.
A Business Service Models the Business Domain
As the name suggests, business services provide business functions. Business services model the business domain. A service is composed of one or more service requests or methods. These service requests represent the published APIs clients can use to access the service.
Let's illustrate with an example. An insurance company has Customer, Policy, Billing, and Claims business services, among others. The Customer service has several service requests or methods such, as find customer, add customer, modify customer, and delete customer. Similarly, the Policy service has quote, issue, endorse, renew, and cancel service requests.
Business services can be represented in a conceptual model. The conceptual model shows how services are related to one another. It ensures that duplicate and overlapping services are not created. It helps provide the oversight for separate groups to leverage existing core assets and avoid duplicating effort.
Note: Business services can be contrasted with technical services. Technical services are interoperable software components, too. However, technical services do not model the business domain, but perform some useful technical function, such as document generation, transformation, printing, or logging.
A Business Service Is Interoperable
Interoperability is one of the key differences between a component and a service-enabled component. A component performs some useful function to homogeneous clients that are written in the same language as the component itself or that run in the same process space. A service exposes a component to heterogeneous clients that can be written in different languages and run in different process spaces.
The component being exposed may be external or internal to the service itself. For example, a database stored procedure or mainframe transaction may be exposed as an interoperable service and be made available to clients that could not otherwise invoke the component. This is depicted in Figure 1. A database stored procedure is exposed as a service to client applications.
Figure 1: Externally exposed component
Optionally, the service may implement the business logic entirely within itself. This is depicted in Figure 2. A rating service implements the business logic internally and does not require a network hop to another resource.
Click here for a larger image.
Figure 2: Internally exposed component
Page 1 of 2
This article was originally published on June 11, 2003


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Since 2006, law enforcement agencies in Bristol County have acquired more than $3 million in surplus equipment from the U.S. Department of Defense.
Since 2006, law enforcement agencies in Bristol County have acquired more than $3 million in surplus equipment from the U.S. Department of Defense.
Public records show that Bristol County acquired the most military equipment of any other Massachusetts county in that time. Items the agencies acquired include at least 85 M-16 rifles, as well as other military-grade rifles, Humvees, night vision goggles, three mine-detecting kits, a mine-resistant armored vehicle, ballistic vests and armored helmets.
Local police departments in Southeastern Massachusetts have also obtained more mundane equipment such as office furniture, laptop computers, digital cameras, filing cabinets, auto mechanic tools and generators.
"The 1033 program has provided a lot of police departments with equipment that the taxpayers couldn't afford or provide," Freetown Police Chief Carlton E. Abbott said in referring to the Department of Defense Excess Property Program, which has given out $5.1 billion worth of surplus equipment since 1990.
Police departments have also obtained military-grade equipment through grant programs run by the U.S. departments of Homeland Security and Justice, which have all come under renewed scrutiny as images of police officers wearing combat fatigues and Kevlar helmets, sitting atop armored personnel carriers and pointing sniper rifles at protestors in Ferguson, Missouri, have flooded national news outlets and social media feeds.
The images are fueling a national debate about whether police officers are becoming too "militarized."
"Maybe I'm old school, but I prefer traditional police uniforms rather than the battle dress uniforms and all the military garb. The threshold issue is about how the public perceives the police. At least that's how I look at it," said Abbott, whose department has obtained four Humvees — two are used for spare parts — that police officers have used to evacuate people from flooded areas and to rescue those lost in the Freetown State Forest.
The Westport, Fall River and Swansea police departments have also acquired Humvees to reach people stranded in isolated areas during blizzards and major floods. Those departments, like most police agencies across the country, are not using Humvees for regular neighborhood patrols.
"The real issue is how much of this equipment is making its way into the everyday practice of policing, and that's going to vary. None of this is new, but if you start seeing this equipment and tactics being part and parcel of the everyday policing of our towns, then I would find that to be absolutely disturbing," said Mitchell Librett, a criminal justice professor at Bridgewater State University.
Librett said surplus military equipment, including rifles and machine guns, has long been distributed to law enforcement agencies after conflicts dating back to World War I, when even civilians for a time could buy Thompson submachine guns — "Tommy Guns" — in regular gun stores.
"The larger the war, the more of this stuff becomes available," Librett said.
Congress created the 1033 military-transfer program during the height of the drug war in the early 1990s, when police felt outgunned by the gangs. Now almost 13 years into the "War on Terrorism," with related U.S. military combat in Iraq and Afghanistan, the Pentagon has more combat equipment than ever to give away.
"I would rather have the equipment and never need it, than to need it and never have it," said New Bedford Police Chief David Provencher, whose department requested, and received, 50 5.56-caliber, M-16-style rifles in 2013. Provencher said the department obtained those weapons for its Special Reaction Team, akin to a traditional SWAT team that responds to high-crisis situations like barricaded suspects and active shooters.
Provencher said the New Bedford Police Department also obtained an armored vehicle this year. Massachusetts State Police personnel used the same type of vehicle last year in New Bedford to safely end a standoff with an armed suspect who had barricaded himself in a Phillips Road condominium complex.
"On any given day, the possibility exists in an urban environment where we could be confronted with a situation that requires us to face a large amount of firepower, and that requires special tactics and equipment to negate the threat," Provencher said. "The onus is on us in leadership positions to provide an adequate deterrent, preventive measures and response to that threat."
Public records provided by the Massachusetts State Police — the state coordinator of the 1033 Program — show that several town police departments have requested military-grade weapons. The Swansea Police Department obtained six 5.56-caliber rifles — similar to an M-16 — in 2013. The Somerset Police Department requested 14 7.62-caliber rifles last year.
Somerset police officials did not return messages seeking comment. Swansea Police Chief George Arruda said his department's rifles are kept in the armory.
"If we have to deal with somebody that rises to the level that we need those weapons deployed, then they will be deployed," Arruda said. "There are times when police departments deal with very dangerous people."
For 2013 and 2014 — the years for which 1033 data were available — the Fall River Police Department did not request any surplus military equipment. Fall River police Detective JD Costa, a department spokesman, said the department has acquired three Humvees that are used to search for missing people in wooded areas or to reach individuals stranded by flooding and severe snow storms.
"Anytime we have to go into rough terrain, we'll use the Humvees," Costa said. "We have obtained no other equipment, and at this time, we are not interested in any other equipment."
The Westport Police Department has obtained metal detectors, ballistic-resistant helmets, military backpacks, a generator and three Humvees through the 1033 Program, said Westport Police Detective Jeff Majewski.
"Every department is dealing with tight budgets and where else would you get that stuff besides from decommissioned military sources," Majewski said, adding that the Westport Police Department has not received any weapons from the Department of Defense.
Meanwhile, the Bristol County Sheriff's Department acquired two 7.62-caliber rifles last year. The department has also obtained night vision goggles, two Boston Whaler boats — one was later given to Fall River harbor master — and office furniture. Sheriff Thomas Hodgson said the military rifles are kept for emergency situations.
"You don't want to fall short and have less of an armory than criminals have," Hodgson said. "The weaponry being used against the police nowadays is very serious."
Majewski mentioned the 2004 riots at UMass Dartmouth — where students smashed furniture and threw cinder blocks at police — as the type of situation where conventional police had to rely on SWAT teams because they had necessary crowd control gear like riot shields, longer batons and specialized helmets.
"The tactical helmets, the riot shields, they look mean, but the reality is it's the only way to protect yourself in a (hostile) crowd situation, and obviously you have to have a higher level of training," Majewski said.
However, not everyone is convinced about the need for local police departments acquiring military gear. The ACLU of Massachusetts notes that homicide clearance rates — the rates at which murders are solved — across New England have fallen over the past decade at the same time that law enforcement departments have incorporated "military-style policing."
"A federally orchestrated militarization of local police forces has taken place in secret, without making our communities any safer," Kade Crockford, director of the Technology for Liberty project of the ACLU of Massachusetts, said in prepared remarks. ACLU officials also said that police using military-style tactics, including the use of assault rifles, flash bang grenades and battering rams, have increased the likelihood of civilians being injured and killed.
"Our findings reveal not only the dangers of militarized police, but also the difficulties in determining the extent and impact of those dangers," Carol Rose, executive director of the ACLU of Massachusetts, said in a press release. "At every level — from the police to the state governments to the federal government — there is almost no record-keeping about SWAT or the use of military weapons and vehicles by local law enforcement."
Librett, the Bridgwater State University professor who is also a retired police officer, said he agreed with local police chiefs who obtain military equipment to protect police officers in dangerous situations.
"I'd argue that every police department would benefit to have access to vehicles that could safely transport officers to a setting with an armed subject bent on harming police officers," Librett said.
"These chiefs are absolutely correct. There are situations when the police need to be equipped with these weapons and protective gear. There is no doubt about it. However, does it happen on a daily basis? No. Does it happen often enough to justify the expense of purchasing this equipment new? Probably not."
Policing is an ever-evolving profession, with new technology, equipment and tactics constantly being integrated into the job. However, Librett warned against police departments one day regularly using SWAT teams or deploying patrol officers in fatigues, Humvees and combat gear to routine calls for service.
"Overall, if we were to accept to live in a society where police officers are heavily-armed and have worked this equipment into their everyday patrol style, that would be a very sad and disturbing situation," Librett said. "I don't think we're there."
Email Brian Fraga at firstname.lastname@example.com


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Anti-Doping Update September 25, 2012
By Erin Greene on 25/09/12 at 10:06 am
Ria Damgren Nilsson, ITU executive board member and liaison to ITU's anti-doping team, attended a very important anti-doping conference this past weekend in Stockholm, Sweden.
The two-day Symposium was held at the Karolinska Institue and included sessions on doping regulations in sport and society, why athletes engage in doping, the societal effects of doping and misuse and addiction of drugs.
Included in the session on drug-free sport and society was a presentation by WADA Athlete Committee member Dr. Sara Fischer, who gave an athlete's perspective on the problem of doping in sport.
According to the WADA website, "WADA Director General David Howman delivered the keynote address at an anti-doping symposium in Stockholm on Friday during which he outlined the importance of developing further alliances in the fight against doping in sport."
The Doping as a Public Health Issue symposium was hosted by the Professor Arne Ljungqvist Foundation and welcomed representatives from the World Health Organization, the International Olympic Committee (IOC), the United Nations Education, Science and Cultural Organization (UNESCO), INTERPOL and WADA.
Professor Ljungqvist, the Vice-President of WADA and Chair of the IOC Medical Committee, is one of the longest serving experts in the fight against doping in sport.
During his address, Howman recognized the work of Professor Ljungqvist in protecting the rights of clean athletes over the last two decades. He then gave a detailed explanation of the challenges faced by the anti-doping community, as well as the strategy WADA has for addressing these challenges.
Howman said that "doping is no longer an issue that is confined within elite sporting boundaries. Rather, it is a problem that permeates other areas of our society, and has a much wider impact than it did several decades ago when it first became a major challenge for sport."
The speech made reference to the encroaching involvement of the doping underworld in sport and called on governments and public authorities to enhance their cooperation with the anti-doping community.
Howman confirmed that the agency received increasing evidence of "a social problem of steroids in schools and amongst our security forces, the presence of the criminal underworld in trafficking prohibited substances, and an unregulated supply of non-sanitized drugs through the internet and from profit-making opportunists – including many in local gyms."
He said the issue involved "amateur athletes doping in recreational sports events, young people taking steroids in a bid to look good, and an overall challenge to the values of sport and its integrity through allied activities such as match-fixing, bribery and corruption."
Howman explained that there was a growing need for intelligence and information sharing in conjunction with traditional testing methods as a consequence of increasingly sophisticated doping methods supported by well-resourced entourages.
He also addressed growing evidence of the 'trickle-down effect' of doping. The influence of elite athletes who chose to dope is now being seen in amateur sport, both at youth and veteran levels.
"WADA is hopeful that this gathering will allow the public health message to resonate even more loudly, and help inform a broader section of society about doping issues – both in terms of our physical health and in terms of our moral well being," Mr. Howman told attendees.
For a full copy of Mr. Howman's keynote address, please click here.


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May 10, 2013
During a Q&A segment at a science & technology speech given by President Obama's Science Czar, John P. Holdren, Luke Rudkowski asked him about the statements made in his 1977 book, Ecoscience. In this book, Holdren outlined ways to handle "overpopulation" which included forced abortions and sterilization. Despite co-authoring this book and telling Congress that his beliefs in depopulation has changed, Holdren claimed that he never held those beliefs in the first place.
This article was posted: Friday, May 10, 2013 at 3:33 am
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Hi There,
I'm new to the forum (as a poster- I found the forum even before I had my seizure!), and had eclampsia with my first child, a healthy son born at 42 weeks. He will be 2 on December 1st.
I conceived again on our first try back in April of this year (2011), and miscarried at 5 weeks.
We are thinking about TTC again. I have had a consult with one MFM in Manhattan, and have spoken to another on the phone (who was in the same practice as the first MFM). Not sure whether I liked him or not (the one I had the consult with).
Can anyone recommend good MFMs in Manhattan who are experienced with PE/eclampsia? I am pretty terrified about TTC again. Also about to turn 41 this Friday.
Thanks so much!
MFM recs in NYC
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I am curious: In this vast universe, with as many star systems as the sands of the Ganges, do you think that Shakyamuni is the only Buddha that appears at this time? If so, do you think that Buddhism looks exactly the same as it does here on Earth in each of those places? I ask because you seem quite emphatic about there only being one Buddhadharma and that's the way it arose here on this planet at this particular time.Caz wrote: Certainly Modern Bon is very similar to some forms of Buddhism today but that still doesn't make its refuge worthy. As you know at every age of the turning of Dharma the Dharma of the previous age becomes extinct and is renewed again by the Tathagata in this case Shakyamuni Buddha so for one to suggest that there is a ancient Buddha who's Dharma has been preserved in the form of the Bon religion is nonsense. Buddhist Refuge comes from Buddha you cannot call yourself a Buddhist if your refuge is also placed within Bon as well that's taking eclecticism way to far.
Sure Padmasambhava may have acted skilfully and suppressed the more evil practices that existed within Bon at one point but even with A fully accomplished being such as Padmasambhava cannot produce a existent authentic refuge lineage from where there is none.
Surely, authentic lineage comes from the dharmakaya and not merely by dint of historical connection to a particular being.


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RBC I Researchers in Colorado just came forward with a shocking claim: hydraulic fracturing, or "fracking," the decades-old method of using a high-velocity mixture of water, sand and chemicals to blast through rock to release oil and gas deposits, causes birth defects.
There's just one hitch: it isn't true.
Like many environmental activists' policy positions on natural gas development, this mistaken conclusion is based on a combination of faulty science, selective reading of evidence and ideologically-driven self-deception.
According to Larry Wolk, the executive director of Colorado's Department of Public Health and Environment, "a reader of the study could easily be misled to become overly concerned."
He even warned pregnant women to stay away from the bogus study.
The Colorado fracking example is just the latest of many instances in which environmental activists have allowed ideology to trump science. Consider the spectacular claim, first promulgated in the all-but-fictitious "documentary" Gasland, that fracking causes gas to seep into the water supply in such volume that people can actually set their running water on fire.
Colorado — whose state government is headed by Democratic Gov. John Hickenlooper — investigated the claim, and found that the gas in the Gasland tap was "not related to oil and gas activity" at all, but was rather the result of the water well in question penetrating "at least four different coal beds," which have well-documented occurrences of methane.
Another major groundless claim of fracking opponents is that the chemicals used in the process contaminate drinking water.
Not so, concluded the Environmental Protection Agency (EPA) under President Obama. Former EPA Administrator Lisa Jackson told Congress in 2011 that she knew of no "proven case where the fracking process" affected water.
Then came the bogus assertion of a link between fracking and earthquakes.
A U.S. Geological Survey scientist unequivocally stated that the agency finds "no evidence that (hydraulic fracturing) is related to the occurrence of earthquakes." Yet such claims often garner headlines and require many man-hours of review and investigation only to determine they are baseless.
Let's be clear about the stakes in these phony claims about fracking: A recent study by the respected research unit IHS CERA found that unconventional energy development, such as fracking and horizontal drilling, supported 2.1 million jobs last year and contributed $284 billion to the U.S. economy.
By 2025, the total could be 3.9 million jobs and $500 billion of our economy. But that's only if the industry is allowed to expand to its full potential. If they are successful, anti-fracking fabulists will destroy a major contributor to U.S. economic growth and energy independence.
Environmentalists often claim that those who doubt that human activity is contributing to climate change are denying scientific fact. Yet their concern for the facts when the subject is fracking is nowhere near as scrupulous.
Those who oppose natural gas development in this country should hold themselves to the same high standard of scientific veracity they require of others.
Drew Johnson is a senior fellow at the Taxpayers Protection Alliance, a nonpartisan, nonprofit educational organization dedicated to a smaller, more responsible government.


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Browsing Cornell University Graduate School by Subject "x-ray diffraction"
Now showing items 1-2 of 2
High Resolution Techniques For Quantifying Lattice Strains In Polycrystalline Solids During Mechanical Loading Using X-Ray Diffraction (2011-05-31)Understanding the conditions that drive phenomena like fatigue crack initiation in polycrystalline samples requires knowledge of the stress state at the crystal scale. Even during uniaxial tensile loading, the stress state ...
Measuring Micromechanical Behavior for Polycrystalline Materials under Cyclic Loading (2008-08-19)Understanding the crack initiation and propagation mechanisms of a polycrystalline material under cyclic loading remains a challenging problem. Complicated crystal stresses arising from single crystal anisotropy and complex ...