Cybersecurity: mapping the ethical terrain

This edited collection examines the ethical trade-offs involved in cybersecurity: between security and privacy; individual rights and the good of a society; and between the types of burdens placed on particular groups in order to protect others. Foreword Governments and society are increasingly reliant on cyber systems. Yet the more reliant we are upon cyber systems, the more vulnerable we are to serious harm should these systems be attacked or used in an attack. This problem of reliance and vulnerability is driving a concern with securing cyberspace. For example, a ‘cybersecurity’ team now forms part of the US Secret Service. Its job is to respond to cyber-attacks in specific environments such as elevators in a building that hosts politically vulnerable individuals, for example, state representatives. Cybersecurity aims to protect cyberinfrastructure from cyber-attacks; the concerning aspect of the threat from cyber-attack is the potential for serious harm that damage to cyber-infrastructure presents to resources and people. These types of threats to cybersecurity might simply target information and communication systems: a distributed denial of service (DDoS) attack on a government website does not harm a website in any direct way, but prevents its normal use by stifling the ability of users to connect to the site. Alternatively, cyber-attacks might disrupt physical devices or resources, such as the Stuxnet virus, which caused the malfunction and destruction of Iranian nuclear centrifuges. Cyber-attacks might also enhance activities that are enabled through cyberspace, such as the use of online media by extremists to recruit members and promote radicalisation. Cyber-attacks are diverse: as a result, cybersecurity requires a comparable diversity of approaches. Cyber-attacks can have powerful impacts on people’s lives, and so—in liberal democratic societies at least—governments have a duty to ensure cybersecurity in order to protect the inhabitants within their own jurisdiction and, arguably, the people of other nations. But, as recent events following the revelations of Edward Snowden have demonstrated, there is a risk that the governmental pursuit of cybersecurity might overstep the mark and subvert fundamental privacy rights. Popular comment on these episodes advocates transparency of government processes, yet given that cybersecurity risks represent major challenges to national security, it is unlikely that simple transparency will suffice. Managing the risks of cybersecurity involves trade-offs: between security and privacy; individual rights and the good of a society; and types of burdens placed on particular groups in order to protect others. These trade-offs are often ethical trade-offs, involving questions of how we act, what values we should aim to promote, and what means of anticipating and responding to the risks are reasonably—and publicly—justifiable. This Occasional Paper (prepared for the National Security College) provides a brief conceptual analysis of cybersecurity, demonstrates the relevance of ethics to cybersecurity and outlines various ways in which to approach ethical decision-making when responding to cyber-attacks

Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack

This is the final version. Available from Wiley via the DOI in this recordBACKGROUND: Rapid and accurate detection of stroke by paramedics or other emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage. However, their accuracy remains uncertain and there is no agreement which of the scales perform better. OBJECTIVES: To systematically identify and review the evidence pertaining to the test accuracy of validated stroke recognition scales, as used in a prehospital or emergency room (ER) setting to screen people suspected of having stroke. SEARCH METHODS: We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and the Science Citation Index to 30 January 2018. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data. SELECTION CRITERIA: We included studies evaluating the accuracy of stroke recognition scales used in a prehospital or ER setting to identify stroke and transient Ischemic attack (TIA) in people suspected of stroke. The scales had to be applied to actual people and the results compared to a final diagnosis of stroke or TIA. We excluded studies that applied scales to patient records; enrolled only screen-positive participants and without complete 2 × 2 data. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted a two-stage screening of all publications identified by the searches, extracted data and assessed the methodologic quality of the included studies using a tailored version of QUADAS-2. A third review author acted as an arbiter. We recalculated study-level sensitivity and specificity with 95% confidence intervals (CI), and presented them in forest plots and in the receiver operating characteristics (ROC) space. When a sufficient number of studies reported the accuracy of the test in the same setting (prehospital or ER) and the level of heterogeneity was relatively low, we pooled the results using the bivariate random-effects model. We plotted the results in the summary ROC (SROC) space presenting an estimate point (mean sensitivity and specificity) with 95% CI and prediction regions. Because of the small number of studies, we did not conduct meta-regression to investigate between-study heterogeneity and the relative accuracy of the scales. Instead, we summarized the results in tables and diagrams, and presented our findings narratively. MAIN RESULTS: We selected 23 studies for inclusion (22 journal articles and one conference abstract). We evaluated the following scales: Cincinnati Prehospital Stroke Scale (CPSS; 11 studies), Recognition of Stroke in the Emergency Room (ROSIER; eight studies), Face Arm Speech Time (FAST; five studies), Los Angeles Prehospital Stroke Scale (LAPSS; five studies), Melbourne Ambulance Stroke Scale (MASS; three studies), Ontario Prehospital Stroke Screening Tool (OPSST; one study), Medic Prehospital Assessment for Code Stroke (MedPACS; one study) and PreHospital Ambulance Stroke Test (PreHAST; one study). Nine studies compared the accuracy of two or more scales. We considered 12 studies at high risk of bias and one with applicability concerns in the patient selection domain; 14 at unclear risk of bias and one with applicability concerns in the reference standard domain; and the risk of bias in the flow and timing domain was high in one study and unclear in another 16.We pooled the results from five studies evaluating ROSIER in the ER and five studies evaluating LAPSS in a prehospital setting. The studies included in the meta-analysis of ROSIER were of relatively good methodologic quality and produced a summary sensitivity of 0.88 (95% CI 0.84 to 0.91), with the prediction interval ranging from approximately 0.75 to 0.95. This means that the test will miss on average 12% of people with stroke/TIA which, depending on the circumstances, could range from 5% to 25%. We could not obtain a reliable summary estimate of specificity due to extreme heterogeneity in study-level results. The summary sensitivity of LAPSS was 0.83 (95% CI 0.75 to 0.89) and summary specificity 0.93 (95% CI 0.88 to 0.96). However, we were uncertain in the validity of these results as four of the studies were at high and one at uncertain risk of bias. We did not report summary estimates for the rest of the scales, as the number of studies per test per setting was small, the risk of bias was high or uncertain, the results were highly heterogenous, or a combination of these.Studies comparing two or more scales in the same participants reported that ROSIER and FAST had similar accuracy when used in the ER. In the field, CPSS was more sensitive than MedPACS and LAPSS, but had similar sensitivity to that of MASS; and MASS was more sensitive than LAPSS. In contrast, MASS, ROSIER and MedPACS were more specific than CPSS; and the difference in the specificities of MASS and LAPSS was not statistically significant. AUTHORS' CONCLUSIONS: In the field, CPSS had consistently the highest sensitivity and, therefore, should be preferred to other scales. Further evidence is needed to determine its absolute accuracy and whether alternatives scales, such as MASS and ROSIER, which might have comparable sensitivity but higher specificity, should be used instead, to achieve better overall accuracy. In the ER, ROSIER should be the test of choice, as it was evaluated in more studies than FAST and showed consistently high sensitivity. In a cohort of 100 people of whom 62 have stroke/TIA, the test will miss on average seven people with stroke/TIA (ranging from three to 16). We were unable to obtain an estimate of its summary specificity. Because of the small number of studies per test per setting, high risk of bias, substantial differences in study characteristics and large between-study heterogeneity, these findings should be treated as provisional hypotheses that need further verification in better-designed studies.National Institute for Health Research (NIHR

Low back pain research priorities: a survey of primary care practitioners

<p>Abstract</p> <p>Background</p> <p>Despite the large amount of time and money which has been devoted to low back pain research, successful management remains an elusive goal and low back pain continues to place a large burden on the primary care setting. One reason for this may be that the priorities for research are often developed by researchers and funding bodies, with little consideration of the needs of primary care practitioners. This study aimed to determine the research priorities of primary care practitioners who manage low back pain on a day-to-day basis.</p> <p>Methods</p> <p>A modified-Delphi survey of primary care practitioners was conducted, consisting of three rounds of questionnaires. In the first round, 70 practitioners who treat low back pain were each asked to provide up to five questions which they would like answered with respect to low back pain in primary care. The results were collated into a second round questionnaire consisting of 39 priorities, which were rated for importance by each practitioner on a likert-scale. The third round consisted of asking the practitioners to rank the top ten priorities in order of importance.</p> <p>Results</p> <p>Response rates for the modified-Delphi remained above 70% throughout the three rounds. The ten highest ranked priorities included the identification of sub-groups of patients that respond optimally to different treatments, evaluation of different exercise approaches in the management of low back pain, self-management of low back pain, and comparison of different treatment approaches by primary care professions treating low back pain.</p> <p>Conclusion</p> <p>Practitioners identified a need for more information on a variety of topics, including diagnosis, the effectiveness of treatments, and identification of patient characteristics which affect treatment and recovery.</p

Blaming the victim, all over again: Waddell and Aylward's biopsychosocial (BPS) model of disability

The biopsychosocial (BPS) model of mental distress, originally conceived by the American psychiatrist George Engel in the 1970s and commonly used in psychiatry and psychology, has been adapted by Gordon Waddell and Mansell Aylward to form the theoretical basis for current UK Government thinking on disability. Most importantly, the Waddell and Aylward version of the BPS has played a key role as the Government has sought to reform spending on out-of- work disability benefits. This paper presents a critique of Waddell and Aylward’s model, examining its origins, its claims and the evidence it employs. We will argue that its potential for genuine inter-disciplinary cooperation and the holistic and humanistic benefits for disabled people as envisaged by Engel are not now, if they ever have been, fully realized. Any potential benefit it may have offered has been eclipsed by its role in Coalition/Conservative government social welfare policies that have blamed the victim and justified restriction of entitlements

Prognosis of chronic low back pain: design of an inception cohort study

BACKGROUND: Although clinical guidelines generally portray chronic low back pain as a condition with a poor prognosis this portrayal is based on studies of potentially unrepresentative survival cohorts. The aim of this study is to describe the prognosis of an inception cohort of people with chronic low back pain presenting for primary care. METHODS/DESIGN: The study will be an inception cohort study with one year follow-up. Participants are drawn from a cohort of consecutive patients presenting with acute low back pain (less than 2 weeks duration) to primary care clinics in Sydney, Australia. Those patients who continue to experience pain at three months, and are therefore classified as having chronic back pain, are invited to participate in the current study. The cohort will be followed up by telephone at baseline, 9 months and 12 months after being diagnosed with chronic low back pain. Recovery from low back pain will be measured by sampling three different outcomes: pain intensity, interference with function due to pain, and work status. Life tables will be generated to determine the one year prognosis of chronic low back pain. Prognostic factors will be assessed using Cox regression. DISCUSSION: This study will determine the prognosis of chronic non-specific low back pain in a representative cohort of patients sourced from primary care. The results of this study will improve understanding of chronic low back pain, allowing clinicians to provide more accurate prognostic information to their patients

Match injuries in amateur Rugby Union: a prospective cohort study - FICS Biennial Symposium Second Prize Research Award

Background: The majority of Rugby Union (rugby) players participate at the amateur level. Knowledge of player characteristics and injury risks is predominantly ascertained from studies on professional or junior athletes in rugby. The objectives of the current study are to: (1) describe the health-related quality of life (HRQoL) and physical characteristics of a cohort of amateur rugby players; (2) describe the incidence, severity and mechanism of match injuries in amateur rugby, and; (3) explore factors associated with rates of match injury in this population. Methods: Participants (n = 125) from one amateur men’s rugby club were followed in a one-season (2012) prospective cohort study. Match injury and match time exposure data were collected. A participant match exposure log was maintained. Baseline variables collected include: participant’s age, playing experience, position of play, the SF-36v2 health survey, height and weight. Injury incidence rates (IIRs) per 1000 match-hours exposure were calculated. Injury sub-groups were compared by calculating rate ratios of two IIRs. Poisson mixed-effects generalised linear modelling was used to explore relationships between IIRs and baseline predictors. Results: A total of 129 injuries occurred during a combined period of 2465 match-hours of exposure. The overall IIR was 52.3 (43.7–62.2) /1000 match-hours exposure. Moderate-severe injuries (>1 week time-loss from play) comprised 36 % of all injuries. Tackling was the most common mechanism of injury, the head/face was the most common body region of injury and sprain/ligament injuries were the most common injury type. Fewer years of rugby participation, lower BMI and lower SF-36v2 mental component summary score were associated with higher IIR in amateur rugby. Age, player position i.e., backs versus forwards and SF-36v2 physical component summary score were not associated with injury incidence. Conclusion: Amateur rugby players report similar HRQoL as the general population. We found amateur players had a higher rate of injury and lower injury severity than previous amateur studies, but location, type, and mechanism were similar. In this study pre-season HRQoL and BMI were weakly associated with higher injury rate when controlling for other factors; a finding that should be interpreted with caution and clarified with future research

Paracetamol, NSAIDS and opioid analgesics for chronic low back pain: A network meta-analysis (Protocol)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To answer the clinical question: ‘what analgesic medicine shall I prescribe this patient with chronic low back pain to reduce their pain?’. The objectives are to determine the analgesic effects, safety, effect on function, and relative rank according to analgesic effect, safety and effect on function of a single course of opioid analgesics, NSAIDs or paracetamol or combinations of these medicines

Prognosis of acute low back pain: design of a prospective inception cohort study

BACKGROUND: Clinical guidelines generally portray acute low back pain as a benign and self-limiting condition. However, evidence about the clinical course of acute low back pain is contradictory and the risk of subsequently developing chronic low back pain remains uncertain. There are few high quality prognosis studies and none that have measured pain, disability and return to work over a 12 month period. This study aims to provide the first estimates of the one year prognosis of acute low back pain (pain of less than 2 weeks duration) in patients consulting primary care practitioners. A secondary aim is to identify factors that are associated with the prognosis of low back pain. METHODS/DESIGN: The study is a prospective inception cohort study. Consecutive patients consulting general medical practitioners, physiotherapists and chiropractors in the Sydney metropolitan region will complete a baseline questionnaire regarding their back pain. Subsequently these patients will be followed up by telephone 6 weeks, 3 months and 12 months after the initial consultation. Patients will be considered to have recovered from the episode of back pain if they have no pain and no limitation of activity, and have returned to pre-injury work status. Life tables will be generated to determine the one year prognosis of acute low back pain. Prognostic factors will be assessed using Cox regression. DISCUSSION: This study will provide the first estimates of the one year prognosis of acute low back pain in a representative sample of primary care patients