Developing innovative, efficient, and institutionally scalable biospecimen consent for remnant tissue that meets the National Institutes of Health consent guidelines for genomic and molecular analysis is essential for precision medicine efforts in cancer.This study aims to pilot-test an electronic video consent that individuals could complete largely on their own.The University of California, Los Angeles developed a video consenting approach designed to be comprehensive yet fast (around 5 minutes) for providing universal consent for remnant biospecimen collection for research. The approach was piloted in 175 patients who were coming in for routine services in laboratory medicine, radiology, oncology, and hospital admissions. The pilot yielded 164 completed postconsent surveys. The pilot assessed the usefulness, ease, and trustworthiness of the video consent. In addition, we explored drivers for opting in or opting out.P=.005) and the ability to understand the information (P<.001). There were significant differences between those who opted in and opted out in their beliefs concerning the usefulness of tissue, trusting researchers, the importance of contributing to science, and privacy risk (P<.001). The results showed that “I trust researchers to use leftover biological specimens to promote the public’s health” and “Sharing a biological sample for research is safe because of the privacy protections in place” discriminated opt-in statuses were the strongest predictors (both areas under the curve were 0.88). Privacy concerns seemed universal in individuals who opted out.The pilot demonstrated that the electronic video consent was well received by patients, with high scores for usefulness, ease, and trustworthiness even among patients that opted out of participation. The revised more animated video pilot test in phase 2 was better received in terms of ease of use (Efforts to better educate the community may be needed to help overcome some of the barriers in engaging individuals to participate in precision health initiatives. Informed consent for biospecimens is an essential component for a robust program in precision medicine (PM). The use of deidentified remnant (leftover) biospecimens has come under recent scrutiny. Although the Notice of Proposed Rule Making (NPRM) to Human Subject Federal Regulations (common rule)  considerGeneral requirements of study-specific informed consent1. Obtaining the legally effective informed consent of the participant or the participant’s legally authorized representative2. Seeking informed consent under circumstances that provide an opportunity to discuss and consider whether or not to participate and that minimize the possibility of coercion or undue influence3. Providing information in understandable language4. Providing information that a reasonable person would want to have to make an informed decision about whether to participate and providing an opportunity to discuss that information5. Avoiding exculpatory language: Exculpatory language either waives or appears to waive the participant’s legal rights or it releases or appears to release the investigator, the sponsor, the institution, or its agents from liability for negligence.Basic elements of study-specific informed consent6. A description of any reasonably foreseeable risks or discomforts to the participant7. A description of any benefits to the participant or to others that may reasonably be expected from the research8. A statement describing the extent, if any, to which confidentiality of records identifying the participant will be maintained9. A statement that participation is voluntary and that the participant may choose not to participate or discontinue participation at any time without penalty or loss of benefits to which the participant is otherwise entitled10. A statement that the participant's biospecimens—even if identifiers are removed—may be used for commercial profit11. A statement about whether the participant will or will not share in the profit12. A statement indicating if the research will or might include whole genome sequencingUnique elements of a broad universal consent for biospecimens13. A statement describing the types of research that may be conducted, and the information must be sufficient for a reasonable person to conclude that he or she would consent to the types of research anticipated14. A statement describing if possible future research could raise particularly sensitive ethical, moral, religious, or cultural issues, in addition to a statement that advises the participant of the possibility that he or she might have chosen not to consent to some of those specific research studies that will use the biospecimens15. A statement describing the identifiable private information or identifiable biospecimens that might be used in research, whether sharing of the information or biospecimens might occur, and the types of institutions or researchers that might conduct research with the information or biospecimens16. A statement describing how long the information or biospecimens may be stored and maintained and how long the information or biospecimens may be used for research purposes; these time periods may be indefinite17. A statement that clinically relevant research results may not be disclosed to the participant18. A statement informing the participant whom to contact for answers to questions about the participant’s rights regarding storage and use of information or biospecimens and whom to contact regarding research-related harmTraditionally, in-person paper consents are often resource intensive, not easily scalable, and preclude digital responses from being incorporated in the electronic health record and laboratory information management systems. Given that PM requires large-scale patient engagement, innovations in consenting in conjunction with broad public education ,6 are reEngageUC, an NIH-funded study, examined biobanking in the University of California system with community constituents to better define the innovative and accessible consent materials needed as part of a scalable institutional biobanking program in support of PM ,11. The In this study, we engaged the community and stakeholders across the University of California, Los Angeles (UCLA) Health System, David Geffen School of Medicine at UCLA, UCLA Institute of Precision Health, and the UCLA Clinical and Translational Science Institute (CTSI) to create and pilot an innovative potentially scalable universal video consent that asks patients to give a “broad” or “one time” consent that allows researchers to use their biomaterial and clinical data in a manner that meets the criteria defined by both the NIH and NPRM .This study was approved by the UCLA Institutional Review Board  with a waiver of written informed consent.We formulated a strong governance structure, including a community advisory board (CAB), to oversee and give feedback on the consent design and process .Our study team assembled a CAB consisting of 11 respected leaders that were highly involved with organizations in the Los Angeles region that understood our diverse communities and represented their perspectives. The members were racially diverse  and equitable with respect to gender .The committee held five meetings between July 2015 and June 2019 to review and guide the video design. The CAB’s primary focus was to ensure the video was easy to understand and explained the purpose of the consent. The board additionally focused on three key areas: inclusion of diverse patients in PM education, outreach, and research; integration of research and clinical operations; and potential return of genetic results.The internal advisory board included our institutional research leaders from the David Geffen School of Medicine, Institute of Precision Health, CTSI, UCLA Health, and additional faculty with expertise in bioethics, patient engagement, biobanking, and IRB. The members of the internal advisory board provided substantial feedback to ensure the video content was informative, met NIH standards, addressed both genetic testing and the potential for collaborations with external companies and federal partners, was culturally sensitive, and represented the diversity of Los Angeles.The content for both the text and animated video consents were adapted from paper versions of a biobanking consent developed by EngageUC . The aniA text-based video (text moving from screen to screen) was first designed to consent patients around the use of their remnant tissue for research. A convenience sample of 125 patients were enrolled but only 123 completed postconsent surveys see .Our CAB and internal advisory board guided the adaptation of the universal consent video to a fully animated (cartoon-like) video to better communicate content to lay audiences and use this to power the Institute of Precision Health ATLAS biobank see . The vidThe first pilot was conducted at five distinct locations within UCLA Ronald Reagan Hospital: (1) hospital admissions, (2) clinical lab, (3) mammography clinic, (4) oncology clinic, and (5) liver clinic. Technical assistance was available at all these locations. Sites were selected because of their diverse populations and high volume . All patients were approached and technical assistance from study staff was made available. The second pilot was expanded to include perioperative suites. Patients had to validate their identity before viewing the video and responding to the consent questions see .Patients were asked to choose their preferred language (English or Spanish) and then validate their identity by entering their medical record number, selecting their birth year (out of 6), and entering the initials of their first and last name. Once validated, individuals could view the video and provide consent. There was no prompting from study staff or clinic personnel. A paper brochure with frequently asked questions  was handed to patients with the iPad. Both the video and the FAQs let patients know they could change their consent status at any time. After watching the video, patients were asked: where they wanted to opt in or opt out of having remnant biospecimens used for research and if they would be open to recontact for future research.Demographic data, including age, race or ethnicity, highest level of education, and language preference for the convenience sample, were collected.Patient impressions of the universal consent videos were evaluated with three questions  using a five-point Likert scale .A postconsent survey was developed in English and Spanish to evaluate the effectiveness of the universal consent videos and understand drivers of consent choice. Patients were approached after completing the universal consent videos. Volunteers received a US $5 dollar Target gift card to compensate them for their time. opted in received additional questions to determine drivers . Individuals who opted out received additional questions to determine drivers .The internal advisory board helped develop questions used to understand the reasons patients’ opted in or out. Individuals who The study team developed a 10-item questionnaire to evaluate patients’ beliefs about biomedical research using validated instruments as guides -16. ThisThe patient’s decision to either opt in or opt out of sharing their remnant samples was recorded. We also tracked the number of patients who agreed to be contacted for future research.P values were reported, and variables were considered statistically significant if the P value was <.05. All analyses were conducted using Stata 15 (StataCorp) [Demographic information, consent rates, and patient ratings about consent were summarized using descriptive statistics including medians, ranges, and percentages. The video script was run through the Flesh-Kinkaid Readability Test tool in Word (Microsoft Corporation) to determine the grade level of the universal consent videos. The patient characteristics between those that opted in and opted out were compared with chi-square tests for homogeneity. The consent rates were compared between phases 1 and 2 consents with chi-square tests for homogeneity. Patients’ evaluation of the usefulness, ease, and trustworthiness of the videos in phases 1 and 2 were compared using Wilcoxon rank sum tests since the variables had skewed distributions. To determine the internal consistency of the 10-item beliefs survey, Cronbach alpha was used. Univariate logistic regression was used to examine the association between patients’ beliefs and their consent decision. We used the AUC receiver operating characteristic curves to predict which patients opted in versus opted out. Two-sided ataCorp) .The CAB played a significant role in the video design, which made the video rich in content, ensured that the language was appropriate for the lay population, addressed the most concerning questions from the community, was applicable to a diverse population, and was less than 5 minutes in duration. The board’s primary focus was to ensure that the video was understandable and appropriately explained why UCLA was asking them to donate biosamples and clinical data for research. The board additionally focused on three key areas: (1) how to ensure the inclusion of diverse patients and communities in PM program education, outreach, and research; (2) if and how to return PM research findings to individual patients who contribute samples and data to the biobank; and (3) how to appropriately bridge research and clinical operations.A total of 175 patients enrolled across the two pilot phases, of which 173 actually went through the electronic video consent see . The popP=.41). Across the entire cohort, 56% (97/173) of individuals agreed to be recontacted to participate in other biomedical research projects.There was no significant difference for consent rate between the two phases . Additionally, we calculated AUC to evaluate the ability of the questions to discriminate which question predicted patients opting in. The results showed that “I trust researchers to use leftover biological specimens to promote the public's health” and “Sharing a biological sample for research is safe because of the privacy protections in place” discriminated opt-in statuses were the strongest predictors .We also examined whether there was a difference between the video consent evaluations of patients who opted in and opted out regarding the ease of use, usefulness, and the trustworthiness as three outcomes: useful and not useful, easy to understand and not easy to understand, and trustworthy and not trustworthy, respectively. In terms of where it was useful or easy to understand, the universal consent video did not differ between two groups (those who opted in vs opted out). However, 88.4% (136/158) of the patients who opted in felt they could trust the information in the video compared to only 53.3% (8/15) of the patients who opted out (P=.005) and the ability to understand this information (P<.001). There was no significant difference regarding the trustworthiness between the text-based video and animated video  responding as “moderate” or “very important” were a key focus. Among the four questions we asked the patients who opted in , three oOur study indicated that our universal consent animated video is easy and informative. Because it is short and self-administered, this is a possible solution for a scalable consent method for population-based PM research. Compared to in-person paper consent, electronic video consent requires fewer human resources and less physical space. As designed in this study, it could be deployed to any number of devices and applied at multiple medical locations. Hence, it is suitable for large-scale efforts to collect informed consent from a large population with a modest incremental cost. Furthermore, it allows patients a safe space to participate in the consenting process without the pressure an in-person process might create. To apply it broadly and effectively to diverse populations, it is critical that the universal consent video addresses potential concerns participants may have about the research project to build trust, reassure potential participants about privacy concerns, be transparent (which further increases trust), and address the potential of the research.In line with other studies, we found that trust is one of the most important factors for patients opting in to biomedical research . MultiplDelivering comprehensive information about biobanking and PM research is necessary for truly informed consent and to build patients’ trust. However, it is important to balance the video content and length, as patients might lose interest or read or watch the consent cursorily if it is too long or if the content is not presented in language that average individuals can understand -25. One In this study, all (100%) patients who opted out responded that concerns about privacy were moderately or very important to them. This is consistent with results from multiple studies suggesting that patients were concerned about misuse of their personal data . If patiOur study found that potential participants’ health beliefs were the most significant driver of their willingness to participate in a precision health initiative. Patients who opted in believed that their participation could advance science, find cures for disease, and help others. This confirms previous studies that participation in biobank research was based on altruistic motivations and responsibilities to assist future generations . TogetheThis pilot study has its limitations. This study only included a convenience sample of patients who agreed to do the electronic consent and answer the additional survey. The sample size was small, and there were smaller subgroups in each category of race, age, gender, and educational level, which limited our ability to evaluate any differences between these populations. We also did not evaluate the participants’ health statuses, which prevented us from understanding if differences in consent rate and health beliefs exist among patients with different diagnoses or disease burden. Future research needs to evaluate the electronic video consent performance in a larger population, so these and other potentially important variables such as low health literacy can be studied more comprehensively.In summary, we created and piloted an innovative electronic video consent that was self-administered and easy to understand for patients. This approach will next be tested for scalability as an enterprise solution by expanding across 18 clinical sites across the UCLA health system. Future goals include expansion to other University of California sites and piloting the video and process in affiliated county hospitals within the larger Los Angeles County. We believe our video consent and process offer an approach that would allow for more robust inclusion of institutions that do not have the financial resources to use employees for in-person consent. Given the reality that many such institutions will serve patients who are chronically ill, of lower socioeconomic status, and who are from underrepresented minority populations, our video consent and process offer the possibility for these groups to become better represented in PM research. The importance of participation in PM remain unclear especially among ethnic minority populations.


Alcohol consumption is a major contributor to the disease burden among adolescents. The adolescent alcohol abstainer is still often depicted as problematic in the research literature and in prominent theoretical frameworks. However, over the past two decades, there has been a marked trend of declining youth drinking in Sweden. The declining trend has led to a shift in the majority behaviour of youth, from drinking to non-drinking. It is plausible that this trend has also shifted the position of non-drinkers. This paper examines the position of non-drinkers in a nationally representative sample of Swedish adolescents. A survey was carried out in 2017 in 500 randomly selected schools. A total of 5549 respondents (15–16-year-olds) agreed to participate and answered the questionnaire. A minority (42.8%) had consumed alcohol during their lifetime. The results show that non-drinkers had better health and school performance when compared to drinkers. The results also showed that there were no differences in the social position between non-drinkers and drinkers. These findings are new and indicate a changed position of non-drinkers among Swedish adolescents. With non-drinking being the majority behaviour among Swedish adolescents this seems to have shifted the position of non-drinkers. There is a need for research on the long-term importance of not drinking during adolescence. Alcohol is a major contributor to the global burden of disease  and is tThere is a paucity of general population studies focussing on alcohol abstainers. This is most likely due to the fact that in most European countries alcohol consumption is normative with a majority of the population being alcohol consumers. In Sweden, nine out of ten adults have consumed alcohol during the past year . That moDrinking also used to be the norm among youth. For example, in the past year prevalence rates of alcohol consumption were between 80 and 90 per cent among Swedish ninth graders between the 1970s and 1990s [A commonly found result is that non-drinking youth, compared to drinkers, have better somatic health and perform better in school ,10. HoweSeveral prominent theoretical frameworks also depict the adolescent abstainer as problematic. Both Problem Behavior Theory (PBT) and Moffitt’s theory of delinquency describe the adolescent abstainers as groups troubled by problems ,17. MoffHowever, whilst such models may have been useful for the understanding of non-drinking during prior decades, there are strong indicators that they now are quite outdated. Since the turn of the millennium, youth drinking has changed radically in Sweden as elsewhere. The prevalence of drinking among 15–16-year-olds has steadily declined from 81 per cent in the year 2000 to only 39 per cent in 2018 ,20,21,22According to the normalization theory by Parker et al. , when a The aim of the present study is therefore to use a nationally representative sample of Swedish ninth graders from 2017, where the majority were non-drinkers, to compare Swedish youth that drank alcohol with those not drinking with respect to their social relations, self-rated somatic health, mental health and school situation. Besides these overall comparisons, we also compare drinkers and non-drinkers separately for boys and girls. The purpose of these comparisons is not to assess causal relations, but to examine the social markers of alcohol consumption in light of the marked changes in youth drinking that has occurred over the past two decades in Sweden.n = 343). In each of the sampled schools, one class was then selected using a PPS sampling procedure. All students in the selected class who were present on the day of the survey were then asked to participate in the study. Those agreeing to participate were asked to fill out a self-administered paper-and-pen questionnaire during school hours. The sample comprised 5549 ninth grade students and the response rate was 82.3%. The study was approved by the ethical review board of Stockholm (2017/5:2).This study used a national sample of Swedish ninth graders (15–16-year-olds) collected in 2017. A random sample of 500 schools was drawn by statistics Sweden (SCB). A probability proportional-to-size sampling design (PPS) was applied where a school’s inclusion probability was proportional to its number of ninth-grade students. The participation rate for schools was 68.6%  was measured with the question “How often do you have six or more drinks on one occasion?”, with the response alternatives “Never/Less than monthly/Monthly/Weekly/Daily or almost daily”. This was dichotomised into “Less than monthly = 0” and “Monthly or more often = 1”.Psychosomatic problems (PSP) were measured with five questions. “During the past six months, how often have you… had stomach aches, felt stressed, had difficulties keeping awake during class, had trouble falling asleep, had headaches?”. Response alternatives were “Every day = 5, A few times per week = 4, Once a week = 3, A few times per month = 2, More seldom or never = 1”. These were summarized into an overall PSP-scale, range 5–25 . Higher values on this composite measure were thus indicative of more psychosomatic problems, either through experiencing several problems or a higher frequency of problems.Self-rated somatic health (SRH) was measured with the question “If you think about your health in general, how would you say that you feel?”, with the response options “Very good = 5, Good = 4, Neither good or bad = 3, Poor = 2 and Very poor = 1”.Three sub-scales from the Strengths and Difficulties Questionnaire (SDQ) were used . The SweFriendship satisfaction was measured with the question “How satisfied are you usually with the relationship to your friends?”, with the response alternatives “Very satisifed = 4, Satisifed = 3, Not so satisifed = 2, Not satisifed = 1 and Do not know = Missing”.The respondents were asked to report their grades for the last semester in three subjects  on a scale from A-F. These were recoded as follows; A = 20, B = 17.5, C = 15, D = 12.5, E = 10 and F = 0. This was then summarized into a scale ranging from 0–60 where higher values indicate better school performance.School satisfaction was measured with the question “How do you like school?”, with the response alternatives “Very good = 5, Fairly good = 4, Neither good nor bad = 3, Pretty bad = 2 and Very bad = 1”.Truancy was measured with the question “Do you ever play truant?”, with the response alternatives “No = 1, Yes, a few times per semester = 2, Yes, about once a month = 3, Yes, 2–3 times per month = 4, Yes, about once a week = 5 and Yes, several times per week = 6”.p < 0.05 for all analyses.We included only respondents with valid answers to all variables included, resulting in a final analytical sample of 5099 . In the final sample, 48.9% were boys. Descriptive comparisons were made between drinkers and non-drinkers. Differences were tested using t-tests. The significance level was set at The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical reasons.Of the sample, 42.8 per cent reported ever having a drink of alcohol. The sub-group of drinkers reporting HED once a month or more often had more psychosomatic problems than the drinkers and non-drinkers, whilst there were no differences in how they rated their somatic health when compared to drinkers. The sub-group with HED also had lower grades and markedly higher rates of truancy compared to both the other groups.From For boys, the patterns were very similar to those found for girls. Non-drinking boys rated their health better, had fewer psychosomatic problems and had a lower score on the external sub-scale of the SDQ. No difference was found for the internal sub-scale of the SDQ. Non-drinkers also had higher grade-point averages, higher school satisfaction and lower rates of truancy. When it comes to social relations, non-drinking boys had a higher score on the pro-social sub-scale of the SDQ whilst they reported lower satisfaction with their friendships.The major aim of this study was to compare Swedish youths that drink alcohol with those that do not drink alcohol regarding health, mental health, school situation and social situation. In general, only very small differences were observed between the two groups. Where differences were found they consistently showed that non-drinking Swedish ninth graders in 2017 were better off than their drinking peers. They had fewer psychosomatic problems and fewer externalizing problems. Their school situation was also better with higher school satisfaction, higher grade point average and less truancy. This is in line with previous research showing non-drinkers to be more well-adapted and healthier ,11,26. SThe results indicate that the marked changes in youth drinking that have occurred over the past two decades have also shifted the social marker of alcohol so that it is no longer a deviant behaviour among youth not to drink. In this ‘dry’ period it is instead the drinkers that display somewhat lower sociability and worse health. A further interpretation of our results would suggest that not drinking alcohol is no longer a deviant behaviour in this age group in Sweden according to the definition of problem behaviour by Jessor .Our results echo those of two recent qualitative studies from Norway  and SwedMeasham et al. studied illicit drug use among British adolescents during the 1990s when there was a sharp increase in the prevalence of use . They hyThe trends in youth drinking are still unexplained and we do not know what is behind the decrease in drinking and the rise of non-drinking ,22,30. MThe present study was based on cross-sectional data and all information is based on self-reports. This needs to be kept in mind when interpreting the results. The drinking status of the youth might have been wrongly reported and has only been reported on one occasion. Since data was collected at an age when many begin experimenting with alcohol several of the non-drinkers might have transitioned to drinking shortly after participating in the survey. The drinking status should thus not be interpreted as a persistent trait of the youth. The cross-sectional design of the study does not allow us any opportunity to study the direction of associations and thus we do not know if it is the drinking status of the youth that renders the differences in the other variables or if it is the other way around. Most likely several of the associations are reciprocal. Our focus in this paper, however, was on the position of non-drinkers rather than determinants or consequences of their drinking status, which should make these issues less salient. The major strength of the current study is the large nationally representative sample. The survey also had a high response rate. Data covers roughly 5–6% of all ninth graders in Sweden in 2017. Our findings should therefore be valid for the population and not subject to regional variations or particular sub-groups of Swedish youth. The large sample also provides us with sufficient statistical power so that our observations are not merely random variations between the groups.Since the drinking status of these youth is probably not a persistent trait, future studies need to examine the prevalence of transitions to drinking and when this transition occurs. It would also be interesting to examine if non-drinkers do become marginalized at the age when the majority has started to drink or if the tolerance for non-drinkers in this ‘dry’ generation has changed permanently. There is also a paucity of studies on the importance of non-drinking in a longitudinal perspective. The results of the present study show that non-drinkers are better off in a cross-sectional perspective, but it should be studied if not drinking during adolescence also renders long term benefits.In light of the trends reported for adolescents with sharp increases in rates of non-drinkers, we would also argue that there is a need to start researching abstinence or not drinking since this is now the majority behaviour among youth in many western countries.Over the past two decades, there has been a trend of declining drinking among Swedish ninth graders, and in 2017 a minority of Swedish ninth graders were alcohol consumers. There were small differences between drinkers and non-drinkers in self-rated health, psychosomatic problems, school situation and social position. This indicates a shift in the social marker of alcohol consumption among Swedish youth.


Plasmodium falciparum circumsporozoite protein (PfCSP). We have recently isolated human antibodies that target the junctional region between the N-terminal and repeat domains that are not included in RTS,S. Due to the fact that these antibodies protect against malaria challenge in mice, their epitopes could be effective vaccine targets. Here, we developed immunogens displaying PfCSP junctional epitopes by genetic fusion to either the N-terminus or B domain loop of the E2 protein from chikungunya (CHIK) alphavirus and produced CHIK virus-like particles (CHIK-VLPs). The structural integrity of these junctional-epitope–CHIK-VLP immunogens was confirmed by negative-stain electron microscopy. Immunization of these CHIK-VLP immunogens reduced parasite liver load by up to 95% in a mouse model of malaria infection and elicited better protection than when displayed on keyhole limpet hemocyanin, a commonly used immunogenic carrier. Protection correlated with PfCSP serum titer. Of note, different junctional sequences elicited qualitatively different reactivities to overlapping PfCSP peptides. Overall, these results show that the junctional epitopes of PfCSP can induce protective responses when displayed on CHIK-VLP immunogens and provide a basis for the development of a next generation malaria vaccine to expand the breadth of anti-PfCSP immunity.The most advanced malaria vaccine, RTS,S, includes the central repeat and C-terminal domains of the  Plasmodium parasite, several species of which can infect humans. Plasmodium falciparum (Pf), which is found primarily throughout sub-Saharan Africa and Southeast Asia, causes the most severe human disease, with children and pregnant women being most susceptible .IV challenges were performed as previously described . Brieflyescribed . ApproxiThe human PfCSP mAbs CIS43 and L9 preferentially target unique junctional epitopes that are found at the interface between the N-terminal and major repeat domains. Short 15-mer overlapping peptides can be used to map the binding of these mAbs, with CIS43 binding to PfCSP being most strongly competed with by peptide 21 (NPDPNANPNVDPNAN) and L9 binding most strongly competed with by peptide 22 (NANPNVDPNANPNVD) (N); (2) inserting a sequence that spanned from peptide 21 to peptide 24 (p21-24), which contains epitopes for CIS43 and L9, to the N-terminus of E2 (CHIK-p21-24N); (3) inserting peptide 21 to the B domain of E2 (CHIK-p21B); (4) inserting peptide 21 into the N-terminus and the B domain of E2 (CHIK-p21N/p21B); (5) inserting a sequence spanning from peptide 21 to peptide 23 (p21-23), which contains epitopes for CIS43 and L9 to the N-terminus of E2, and peptide 21 to the B domain of E2 (CHIK-p21-23N/p21B); and (6) inserting p21-23 to both the N-terminus and the B domain of E2 (CHIK-p21-23N/p21-23B).We first investigated incorporating variants of the CIS43 epitope into CHIK-VLP, a highly immunogenic nanoparticle . ImmunogN, CHIK-p21-23N/p21B, and CHIK-p21-23N/p21-23B, each of which also carried the L9 epitope. In contrast, combining Fab L9 with VLPs CHIK-p21N, CHIK-p21B, and CHIK-p21N/p21B, which were devoid of the L9 epitope, did not result in a noticeable increase of particle size, or this increase was below 3 nm. These results indicate that the epitopes of antibodies CIS43 and L9 were presented on the VLPs in accordance with their design and that they were accessible to antibodies on the particle surface and thus, presumably, to B cell receptors.The structural integrity of the VLPs with incorporated PfCSP epitopes was studied using negative-stain electron microscopy (NS-EM). All E2 proteins with inserted PfCSP peptides formed VLPs of expected shape and average diameters in the 75–80 nm range A, indicaThese CHIK-VLP immunogens were found to bind to mAbs CIS43, L9, 1210, and 317, with sub-micromolar affinities by Bio-Layer Interferometry (BLI), however more promiscuity of binding was observed by this method . These fN/p21-23B elicited the highest titer against PfCSP , and sera was obtained at day 10, week 5, and week 8 A. Among st PfCSP B. After st PfCSP C. UnexpeN, CHIK-p21-23N/p21B, or CHIK-p21-23N/p21-23B. As a positive control, recombinant CIS43 was infused just prior to challenge and showed a complete reduction in liver burden. In all three immunized groups, the liver load was significantly reduced (N/p21-23B showing the largest reduction of liver load (~95% reduction). Notably, there was a significant correlation between PfCSP titer and reduction of liver load  on the CHIK-VLP to keyhole limpet hemocyanin (KLH) A. Mice iizations B. Howeveed group C.N and CHIK-p21-23N/p21B elicited antibodies that preferentially bound several peptides spanning the junctional region (20–22), and also tolerated the minor repeat sequence, peptide 44. This profile largely matches that of CIS43, as intended. In contrast, KLH-p21 elicited reactivity that was specific to peptide 21. This narrower reactivity profile does not match that of CIS43 as closely, and notably this construct did not provide significant protection. As was initially observed, with reactivity to peptide 21, 22, and 29 , elicited preferential reactivity to the junctional region, as designed. It seems likely, therefore, that the structural idiosyncrasies of each construct result in the differential scaffolding of the “NPN” motif, which is the structural core often recognized by PfCSP repeat mAbs [N compared to CHIK-p21-23N/p21-23B, specifically the degree to which protection derives from reactivity to the junctional or major repeat epitopes.Of all the immunogens tested, CHIK-p21-23otection ,50. Inte repeats ,51. In ceat mAbs ,33. FurtThe immunogens developed here provide the initial basis for further development of CHIK or other VLP-expressing systems for displaying the epitopes of the potent junctional- and minor repeat-targeting mAbs, CIS43 and L9, respectively. As the CHIK-VLP immunogens developed here displayed PfCSP regions distinct from the RTS,S and R21 immunogens , they could be potentially be co-administered to increase the epitope breadth of responses against PfCSP . AlternaTaken together, the data presented here compel further design of PfCSP immunogens with the goal of improving the breadth of responses to PfCSP, compared to the benchmark of RTS,S. Given that PfCSP is the only known target for pre-erythrocytic malaria vaccination, and the need to improve upon the potency of RTS,S, the incorporation of additional neutralizing epitopes as described here may be key to a second-generation malaria PfCSP vaccine.


Dendritic cells (DCs) in the thymus are involved in central tolerance formation, but they also have other functions in the thymus, such as pathogen recognition. The density changes of human thymic DCs have been hardly investigated. In this study, human thymus samples of various ages were collected for tissue sectioning and staining. The thymic cortex and medulla area as well as the densities of various subsets of thymic DCs were calculated.All common DC subsets were found in the human thymus of various ages. Most DCs had accumulated in the human thymic epithelial space, especially the medulla. We also found that the human thymic cortex had atrophied relatively faster than the medulla, which led to a gradual increase of the area ratio of the medulla to cortex with the increase of age. The densities of DC subsets in the human thymus showed various changes with increasing age, which contributed to the composition changes of DC subsets. The density of plasmacytoid DCs (pDCs) in the human thymus had increased gradually with aging, which suggested that pDCs plays another essential role in the thymus in addition to central tolerance.Inconsistent with the shrinking of the epithelial space in the thymus, the densities of DC subsets in the epithelial space of the thymus are maintained at a constant level with aging to preserve highly efficient autoreactive thymocyte screening. An increasing density of the thymic pDCs with aging implies an extra function of DCs in the thymus beyond central tolerance.The online version contains supplementary material available at 10.1186/s12979-021-00255-8. The thymus is the central lymphoid organ in which T cells develop and mature. During this process, the body executes a series of elaborate mechanisms to remove thymocytes that cannot recognize their own human leukocyte antigen (HLA) or autoreactive thymocytes and finally outputs naive T cells and natural regulatory T cells. This is the formation of central tolerance, which is a critical component of immune tolerance , 2. DisrDendritic cells (DCs) and thymic epithelial cells are the main components for thymocyte screening in the thymus , 6, 7. CSimilar to DCs in other tissues, DCs in the thymus are divided into plasmacytoid dendritic cells (pDCs) and myeloid dendritic cells  . mDCs caAlthough the specific function of DCs determines their role in the immune response, the subset composition of thymic DCs also modulates the generation of thymic Tregs . TherefoThymus tissue was digested into a single cell suspension and dendritic cells in the thymus were analyzed by flow cytometry. We used a lineage cocktail of antibodies to exclude thymocytes, T cells, B cells, NK cells, and macrophages. Cells that were negative for the lineage cocktail and positive for HLA-DR were selected for further analysis. Plasmacytoid DCs (pDCs) were labeled by CD123  were selected to represent the characteristics of thymus changes with age  to determine the densities of pDCs and mDCs. By calculating the percentage of each DC subset, we found that pDCs occupied an increasing proportion in the thymus with ageing. However, because of the marker limitation, it was difficult to label subsets of mDCs, which included CD1c + DCs and CD141+ DCs, by IHC. As shown in Fig. In 2010, Ziegler-Heitbrock, L et al. declared a consensus on a flow cytometry panel for human peripheral blood DCs labeling. In this consensus, Linage negative HLA-DR positive CD11c positive for mDCs, or Linage negative HLA-DR positive BDCA2 positive for pDCs . There iThymus comprises the following two compartments: the thymic epithelial space – the site of thymopoiesis occurs – and the perivascular space. The thymic epithelial space comprises the well-known thymic cortex and medulla. Thymus atrophy means the shrinking of the thymus with ageing in mice; however, in humans, thymus atrophy refers to the decrease in size of the thymic epithelial space with age. Therefore, we focused on the thymic cortex and medulla in this histological research.Thymus atrophy is a normal physiological process, and the most widely accepted hypothesis for its existence is the “disposable-soma” theory. This theory hypothesizes that the body supplies and distributed energy to each organ depending on their importance in the continuation of future generations . Based oWe stained human thymus tissue to further focus on the two compartments of the thymic epithelial space, that is, thymic cortex and medulla. These structures play different roles in the development of thymocytes . In the Similar to the roles of thymic epithelial cells, DCs in human thymus also contribute to central tolerance by inducing the production of naive T cells and nTregs . Both mDBecause of the potential for improving immunity in elderly individuals, restoration of the thymus function is an ascendant research field. However, there were few studies on age-dependent changes in the density of dendritic cells in the thymic epithelial space, and most of these studies were conducted in mice , 27, 28.The significance of changes in the density of DCs with ageing remains currently unclear. The loss of thymopoietic space with age is accompanied by a corresponding decrease in the thymic output of naive T cells and nTregs; however, relatively conserved medulla and the constant density of mDCs in this region retain significant function for negative selection to prevent autoimmunity. In addition, the density of pDCs increased with ageing, which suggests that pDCs play other vital roles even as the thymus undergoes atrophy. This role may not involve the central tolerance induction, but the specific role needs to be further studied.The relative proportion of cortex to medulla structures in human thymus tissue changes with age, and the relative retention of medulla might indicate the importance of central tolerance. The density of plasmacytoid dendritic cells increases gradually, which suggests that some of the functions they perform in human thymus become relatively more important with ageing.n = 23). Samples for flow cytometry were collected in 2016 and 2021 (n = 10). The surgically removed specimens were immediately placed in a specimen transfer box for laboratory processing. All thymus specimens were collected, transferred, and treated in accordance with the regulations of the Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University and under its supervision.Thymus samples were collected from patients that underwent corrective cardiology surgery at the Cardiac Surgery Department of the First Affiliated Hospital of Sun Yat-sen University and Guangdong Provincial People’s Hospital from June to November 2014. The normal thymus samples for histology were obtained from patients aged 4 months to 62 years  staining. However, we only calculated the density of thymic DCs from less than 40 years of age, which avoided a sampling bias because of the excessively scattered epithelial space seen in the thymus from older than 40 years. When we calculated the numbers of DCs and the cortex and medulla areas, we scanned the whole section to avoid sampling bias.3 pieces and digested in RPMI medium, Collagenase D (1 mg/mL), Collagenase IV (1.5 mg/mL), and DNase I (0.05 mg/mL) in an incubator with 5% CO2 for 45 min. The tissue blocks were suspended by shaking every 15 min. After digestion, the tissue blocks were dissociated by pipetting. The sample was passed through a 70-μm filter to prepare a single cell suspension for flow cytometry. A lineage cocktail of antibodies  and antibodies against HLA-DR , CD11c , and CD123  were added to the single cell suspension, followed by incubation for 30 min at 4 °C for staining. For specific staining methods, please refer to a previous study [Thymus samples were cut into approximately 1 mm2O2 solution (Gene tech), followed by incubation with anti-CD11c  or -CD123  primary antibodies overnight at 4 °C. Staining with biotinylated secondary antibody was performed for 1 h at room temperature. Staining was developed using an ABC kit (Gene tech) and DAB kit (Gene tech), and counterstaining was conducted with hematoxylin (BASO).The collected thymus samples were cut into 15 × 15 × 5 mm pieces and fixed in 4% paraformaldehyde (Sigma-Aldrich) for 24 h at room temperature. Selected tissue samples were trimmed for dehydration and embedding in paraffin. After embedding, 4-μm-thick sections of tissue were prepared and mounted on slides. After dewaxing and hydration, the tissue sections were stained with hematoxylin and eosin (BASO) by following a typical procedure. For immunohistochemistry, antigen retrieval was performed on rehydrated tissue by boiling the sections in antigen retrieval Citra Solution (Gene tech). Sections were quenched for 30 min at room temperature in a 3% H2) to obtain the average density of dendritic cells in the cortex or medulla (per mm2).A Nikon ECLIPSE Ni-U series microscope was used to obtain images of HE and IHC staining in thymus tissue sections. Images of whole tissue sections were analyzed by image synthesis software (NIS-Elements D). HE staining was used to calculate the area of the medulla and cortex of thymus tissue. The cortex and medulla of the thymus tissue were circled and the actual size was calculated by NIS-Elements D software. IHC staining was used to calculate the density of dendritic cells. Using NIS-Elements D, the specific numbers of dendritic cells in the cortex and medulla were counted and divided by the area of the cortex or medulla  was fitted by linear regression. Correlation analysis of the age and density of dendritic cells in the thymus and cortex employed linear regression fitting.Additional file 1: Immunofluorescence was used to confirm CD11c and CD123 as the single-specific marker for mDCs and pDCs, respectively. A, CD74 (HLA-DR) and CD123 co-staining; B, CD123 and CD11c co-staining; C, CD74 and CD11c co-staining.


There was no difference in the number of viewers for video duration less than or more than 4 min (p > 0.05). YouTube users prefer low-quality videos over high-quality ones, indicating that viewers cannot differentiate between reliable and potentially biased content. It is critical to enable viewers to critically assimilate information hosted on YouTube to make effective oral healthcare decisions.Halitosis is a common condition that adversely affects quality of life. Through YouTube, people access oral health information. This study aimed to analyze the quality and comprehensiveness of the content, and reliability of halitosis videos hosted on YouTube. In total, 300 videos were collected based on three search keywords, and the number of likes, dislikes, views, duration, interaction index, viewing rate, and source category. Subsequently, the video score, which represents the content quality and comprehensiveness was used to categorize videos as poor, good, and excellent. DISCERN score was used to assess video reliability. Of the 105 videos analyzed, 68 (64.8%) were uploaded by personal users. In general, videos were categorized as poor and have low reliability. Videos sourced from healthcare professionals showed the highest quality, comprehensiveness of the content, and reliability ( Halitosis is a common health problem worldwide that is found in all age groups . HalitosThe problem of halitosis has a complex etiology, but it is often ignored by society. This is because many people who are unaware that they have halitosis or feel ashamed of informing their condition to health professionals ,5. HalitLow self-perception and limited knowledge about halitosis are critical problems faced by sufferers . TherefoThe need for communication through messages and social media is the key reason for many to use the Internet. Social media supports the process of seeking insight related to health, medication, medical care, sharing disease experiences among personal users, and communicating with health professionals or other patients . Among tThe study was approved by the Ethics Committee of the Faculty of Dentistry, Universitas Indonesia, No. 18/Ethical Approval/FKGUI/VIII/2020 with Protocol No. 090190720. This study followed the PRISMA flow diagram for the video selection process ,17. YouTYouTube creates a variety of interactions between its users, which is reflected in the number of likes, dislikes, comments, sharing videos, uploading videos, and more ,14. TherThe quality of YouTube video information was assessed using the Global Quality Scale (GQS), which is based on the quality of information available, as well as assessing the extent to which the observed video is useful . The GQSThe GQS and comprehensiveness scores were then combined to obtain a video score that categorized the videos into poor with scores of 1–6, moderate scores of 7–13, and excellent scores of 14–19 ,23. The p-value < 0.05.Data analyses were performed using the SPSS software . The interclass correlation coefficient (ICC) was used to specify the level of agreement between the two observers. The Kruskal–Wallis test was used to examine the differences in the characteristics of the video variables in the video source category, the video score category, and the DISCERN score category. Moreover, the Mann–Whitney test was carried out to determine the differences in the characteristics of the video variables on the video duration. Statistical analyses were based on the data distribution assumptions for numerical outcomes, purpose of test whether to examine the difference between two or more groups, or to measure strength of associations between variables . Statistn = 68, 64.8%) were uploaded by non-professionals.The inter-observer and intra-observer agreements on video score and DISCERN was good, with values ranging from 0.943 to 0.981. A search of three terms resulted in a total of 300 videos, of which 195 videos were excluded based on the exclusion criteria, and 105 videos were successfully obtained for further analysis . Table 1n = 48, 45.7%). Regarding the comprehensiveness of the video, in the majority, the following contents were not explained in the video: epidemiology, classification, and diagnosis. Meanwhile, content regarding management, prevention, and etiology in general, was only discussed with a brief explanation. According to the total score, based on the 105 videos evaluated, only a few  videos were of the “excellent” category and most of them  were included in the “poor” category.p < 0.05). p > 0.05). There were two variables that showed a statistically significant difference between the video score categories, namely, the interaction index and the DISCERN score. Post hoc analysis test was conducted if Kruskal Wallis test showed p-value < 0.05  that have an impact by decreasing a person’s quality of life. Following the Health Belief Model, a person will make health-related decisions when faced with psychological conditions, such as feeling vulnerable to disease . The useMost videos assessed in this study described etiology, management, and halitosis prevention. However, overall, these videos do not discuss risk factors, epidemiology, classification, and diagnosis. It is arduous to expect every video to have a comprehensively structured discussion. Even though the content described is incomplete, some videos contain pivotal and accurate evidence-based information . More thIn addition, another important aspect showed that videos uploaded by healthcare professionals demonstrate a higher quality of information, comprehensiveness of content, and reliability . InteresIn the meantime, lower-quality videos are often uploaded by non-professional users. Videos with low quality are also more frequently watched by the public because viewers tend to follow suggestions by looking for other people’s personal experiences related to the disease they have experienced . Other sBased on the video duration analysis, there was no difference in the number of viewers for videos less than 4 min and more than 4 min, both of which did not reduce the level of the viewers’ attention. However, the quality and reliability of videos are better for videos that are longer than 4 min. As a result, videos that are more than 4 min are considered efficient to educate viewers. A previous study revealed that videos that are less than 6 min are watched more, and videos with a time scale exceeding 6 to 9 min reduce the viewers’ attention . PreviouVideo sources that come from non-professionals, such as influencers, have the largest number of viewers. Based on the innovation diffusion theory, influencers as video uploaders on YouTube are early adopters who are influential in spreading opinions among other adopters . They foThe limitation in this study was that the search results for videos on YouTube were dynamic, which was presumed to change when new videos were uploaded, and old videos were deleted. During video searches, the results varied according to the date and time of the search. Multiple viewers may use different search terms, and it is possible to obtain mixed video results. YouTube does not facilitate ranking according to the high and low quality of the information contained in the video. This makes it difficult for viewers to obtain videos of good quality, trustworthiness, and those that are worth watching. There is no specifically validated scoring system available to assess the quality and reliability of videos before uploading them on YouTube. Researchers conducted observations and assessments independently, which allowed potential bias when making the assessment, but it can be overcome by conducting an inter-observer test between two observers calculated based on the ICC and producing good agreement on the assessment. Additionally, although bad breath is a lay term for halitosis , furtherEvaluation criteria are needed regarding the quality of the video that is uploaded by each video uploader about halitosis on YouTube, with the hope that viewers can receive useful information, good quality content, and thereby, YouTube can be used as a reliable source of information on halitosis. The strategy for creating an effective health education video is to pay attention to the length of the video so that it is of a span of 4 to 6 min so that it includes comprehensive content without losing the viewers’ attention. Given a large number of poor-quality videos on halitosis, health workers and educational institutions play a fundamental role in improving the quality, comprehensiveness of the content, and reliability of this information to increase viewer eHealth literacy. Likewise, collaborations can be made between individual uploaders or influencers and health workers to reach a vast target audience. This collaboration is expected so that messages or health information can be transferred well and attention can be drawn. It is necessary to include additional references in YouTube videos to ensure that the video is not potentially biased. From this study, it can be concluded that, in general, YouTube videos about halitosis may be categorized as poor according to the content’s comprehensiveness and quality. YouTube users prefer low-quality videos over high-quality ones, which illustrates that viewers cannot differentiate between reliable content and potentially biased content. There is a need to enable viewers to critically assimilate information hosted on YouTube to be able to make effective healthcare decisions. Viewers need to be able to discriminate videos they view.


This study examined the association of alcohol drinking patterns with metabolic syndrome (MetS) and its components in a nationally representative sample of South Korean adults. The cross-sectional study included 12,830 current drinkers (6438 men and 6392 women) who were at least 20 years old. Measures of alcohol drinking patterns included average drinking frequency, usual quantity, and binge drinking frequency over the past year. Multivariate logistic regression was performed to estimate odds ratios and 95% confidence intervals for MetS and its components according to alcohol drinking patterns, and also to examine linear trends in these relationships. The prevalence of MetS was 1822 (26.2%) in men and 1313 (17.5%) in women. After adjusting for potential confounding factors, drinking quantity and binge drinking frequency were positively associated with MetS in both sexes. Regarding components of MetS, while the risk of low HDL cholesterol decreased as drinking frequency increased, other MetS components  worsened. Our results suggest that separate management of each component of MetS will be required to protect cardio-metabolic health, and a healthy drinking culture that refrains from binge drinking should be established in the context of public health. The metabolic syndrome (MetS) is a cluster of risk factors defined by abdominal obesity, high blood pressure, elevated fasting glucose, and dyslipidemia, and is well known to be associated with type 2 diabetes, cardiovascular disease, and mortality ,2,3. TheRegarding alcohol consumption, one of the most common health-related behaviors, it has been reported that a small amount of alcohol has a positive effect on health, but excessive drinking results in serious health problems, including an increased risk of cardiovascular disease, cancer, liver cirrhosis, chronic pancreatitis, and violence ,9,10.The association between MetS and alcohol consumption is complex, with previous studies reporting both protective and detrimental effects ,14,15,16The average per capita alcohol consumption in the Republic of Korea is 10.2 L , higher than the World Health Organization Western Pacific average of 7.3 L . AdditioThis study used data from the seventh Korean National Health and Nutrition Examination Survey 2016–2018 (KNHANES VII), a nationally representative survey conducted by the Korean Ministry of Health and Welfare in South Korea . Each yeThe KNHANES received approval from the Institutional Review Board of the Korea Centers for Disease Control and Prevention (KCDC). All participants in the survey provided written informed consent.Our definitions of MetS and its components were based on the National Cholesterol Education Program Adult Treatment Panel III  and the Waist circumference was measured for each participant at a level midway between the lowest lateral border of the ribs and the uppermost lateral iliac crest, with the participant standing. Body weight and height were measured in light indoor clothing, without shoes, to the nearest 0.1 kg and 0.1 cm, respectively. Blood pressure was measured in the right arm using a standard mercury sphygmomanometer . Blood pressure was measured three times, and the average of the second and third measurements was used. Venous blood samples were collected from subjects after they had fasted for at least 8 h. Levels of total cholesterol, triglycerides, HDL, and fasting blood glucose were measured by enzymatic methods using a model 7600–210 Automatic Analyzer  in a certified clinical laboratory.Self-reported questionnaires were used to assess each participant’s alcohol drinking patterns, including average drinking frequency, usual quantity per drinking day, and the frequency of binge drinking during the last year. Average drinking frequency in the past year was classified as less than once a month, once a month, 2–4 times a month, 2–3 times a week, or more than 4 times a week. Usual drinking quantity per drinking day was classified as 1–2 drinks, 3–4 drinks, 5–6 drinks, 7–9 drinks, or 10 or more drinks. The frequency of binge drinking was classified as none, less than once a month, once a month, once a week, or every day. One drink was defined as 30 mL of liquor or 200 mL of beer, equivalent to 10 g of pure alcohol. Binge drinking was defined as the consumption on a single occasion of 7 or more drinks in men, and 5 or more drinks in women.t-test for continuous variables and the chi-squared test for categorical variables. Odds ratios (OR) and 95% confidence intervals (95% CI) for MetS were calculated after adjusting for confounding variables . Associations of MetS and its components according to alcohol drinking patterns were investigated using a multivariate logistic regression analysis. To detect linear trends in these relationships, multivariate linear regression was also used. Smoking status was categorized as currently smoking or currently nonsmoking; the nonsmoking group included ex-smokers and non-smokers. Household income was divided into quartiles . The educational level was classified as below middle school or above middle school. Regular exercise was defined as at least one of the following conditions: aerobic physical activities of vigorous intensity lasting more than 20 min and performed 3 days each week, or aerobic physical activities of moderate intensity lasting more than 30 min performed 5 days each week, or walking for more than 30 min performed 5 days each week. Occupations were classified as white collar, sales and services, blue collar, or unemployed. Region was defined as urban or rural. All analyses were performed using SAS statistical version 9.4 . All statistical tests were two-sided, and values of p less than 0.05 were considered statistically significant.Data for men and women were analyzed separately. Gender differences were analyzed using the independent The general characteristics of the study population are presented in p for linear trend = 0.0128 in men and 0.0088 in women). Linear trends for the association between usual drinking quantity and MetS were also significant . Men who consumed 7–9 drinks or ≥10 drinks per drinking day had greater risk of MetS than those who consumed 1–2 drinks per drinking day, with the highest risk being among those who consumed ≥ 10 drinks per drinking day . In women, those who consumed 5–6 drinks, 7–9 drinks, or ≥10 drinks per drinking day had increased risk of MetS, and this risk was highest in those who consumed ≥10 drinks per drinking day . The linear relationship between binge drinking frequency and MetS was also significant in men (p < 0.0001), but its statistical significance was borderline in women (p = 0.0631). Compared to the reference group (no binge drinking), the odds ratios for MetS were significantly higher in men who reported binge drinking once a week  or every day . In women, odds ratios for MetS were significantly higher in those who reported binge drinking once a month  or once a week  than in women who reported no binge drinking.p < 0.0001), impaired fasting glucose (p = 0.0004), hypertriglyceridemia (p < 0.0001), and low HDL cholesterol (p < 0.0001). The risks of high blood pressure and hypertriglyceridemia were significantly higher in men who consumed alcohol 2–3 times/week  or ≥4 times/week  than those who consumed alcohol less than once a month, after adjusting for potential confounding factors. The risk of impaired fasting glucose was significantly higher in men who consumed alcohol ≥ 4 times/week  than those who consumed alcohol less than once a month. However, the risk of low HDL cholesterol was significantly lower in men who consumed alcohol 2–3 times/week  or ≥4 times/week  than those who consumed alcohol less than once a month. In addition, men who consumed alcohol 2–4 times/month had lower risk of abdominal obesity  than those who consumed alcohol less than once a month.p for linear trend = 0.0448), high blood pressure (p = 0.0155), and low HDL cholesterol (p < 0.0001). Women who consumed alcohol 2–4 times/month had lower risks of abdominal obesity , hypertriglyceridemia , and low HDL cholesterol  than those who consumed alcohol less than once a month. In addition, the risk of low HDL cholesterol was significantly lower in all groups that consumed alcohol one or more times/month compared to those who consumed alcohol less than once a month. In both men and women, the usual quantity per drinking day had linear associations with abdominal obesity , high blood pressure , impaired fasting glucose , and hypertriglyceridemia . The risks of abdominal obesity and high blood pressure were significantly higher in men who usually consumed 7 or more drinks than in men whose usual quantity was 1–2 drinks. The risks of impaired fasting glucose and hypertriglyceridemia were significantly higher in men who usually consumed 5 or more drinks. On the other hand, men who consumed 5–6 drinks had lower risk of low HDL cholesterol . In women, the risk of abdominal obesity was higher among those whose usual consumption was 3 or more drinks than in those who consumed 1–2 drinks. The risk of high blood pressure was higher in women who usually consumed 5–6 drinks  or 7–9 drinks . The risk of impaired fasting glucose was higher in women who consumed 7–9 drinks  or ≥10 drinks . The risk of hypertriglyceridemia was higher in women who consumed 5–6 drinks  or ≥10 drinks  compared to those who usually consumed 1–2 drinks. The frequency of binge drinking had linear associations with abdominal obesity , high blood pressure (p < 0.0001 in both sexes), impaired fasting glucose , hypertriglyceridemia (p < 0.0001 in men), and low HDL cholesterol (p < 0.0001 in both sexes). Men who reported binge drinking once a month had higher risk of hypertriglyceridemia  than those who reported none. The risks of abdominal obesity, high blood pressure, impaired fasting glucose, and hypertriglyceridemia were also higher in men who reported binge drinking once a week or every day compared to those who reported none. On the other hand, the risk of low HDL cholesterol was significantly lower among men who reported binge drinking once a week or every day than those who reported none. The risk of abdominal obesity was significantly higher in women who reported binge drinking less than once a month  than in those who reported none. The risk of high blood pressure was significantly higher in all groups who reported binge drinking one or more times a month, but the risk of low HDL cholesterol was significantly lower than in those who did not binge drink. In addition, women who reported binge drinking every day had higher risks of impaired fasting glucose  and hypertriglyceridemia .In women , drinkinWe investigated the association of alcohol drinking patterns with MetS and its components among Korean adults. Drinking frequency was significantly associated with MetS only in women. Adjusting for potential confounders, women who consumed alcohol at least 2–4 times/month had lower risk of MetS than women who consumed alcohol less than once a month. This seems to be due to the relatively large influence of inverse associations between drinking frequency and HDL cholesterol and triglyceride levels. In addition, there was no significant association in women between drinking frequency and impaired fasting glucose.A cross-sectional study analyzing data from the 1999–2002 National Health and Nutrition Examination Survey (NHANES) reported that people who consumed alcohol 1–2 times/week showed significantly lower risk of MetS than those who drank less than once a week, after adjusting for age; sex; race; years of education; family history of coronary heart disease, stroke, or diabetes; dietary practice ; cigarette smoking status; physical activity; usual quantity of drinking; and frequency of binge drinking . HoweverRegarding the usual drinking quantity, previous studies reported that men who consumed at least 5–6 drinks per drinking day had higher risks of abdominal obesity, high blood pressure, impaired fasting glucose, and hypertriglyceridemia ,35. SomePrevious studies that investigated the frequency of binge drinking found that, even if binge drinking occurred less than once a week, women had higher risks of abdominal obesity and hypertriglyceridemia, relative to those who did not binge drink, and those who reported binge drinking more often had increased risks of other MetS components, with the exception of low HDL cholesterol ,28,35. OBinge drinking has also been reported in the general population to deteriorate neurological function and increase the risk of dementia and cerebrovascular disease, several types of cancer including the oral cavity, pharynx, esophagus, liver, colon, rectum, and breast (in women) ,37. CardSome previous studies have suggested that light or moderate alcohol drinking plays a protective role in cardio-metabolic health ,39,40. OIn this regard, because associations between the components of MetS and drinking patterns have been shown to vary according to sex and ethnicity, it is necessary to investigate how each component of MetS is related to drinking patterns when we investigate the effect of drinking patterns on cardio-metabolic health. For example, studies examining the mechanism of impaired fasting glucose, one of the components of MetS, indicate that it is linked to insulin resistance, and some studies have reported conflicting directions of the relationship between alcohol consumption and insulin resistance ,44. MoreThis study has some limitations. First, given the cross-sectional design of our study, it was impossible to derive causal inferences about associations between drinking patterns and components of MetS. Second, we used self-reported data on drinking patterns through questionnaire, and thus recall bias and miscategorization of drinking habits are possible. Third, other aspects of drinking behavior, such as drinking with meals and preferred types of alcoholic beverages, were not included in the analysis. In particular, different types of alcohol may be composed of different substances and contribute to different effects, which may affect study findings. However, there are also distinct advantages to the data analyzed here. First, our study population was randomly sampled and is representative of the Korean population. Second, various potential confounding variables that can affect the relationship between drinking patterns and MetS components were considered, and we included statistical tests to evaluate linear relationships.The current study observed that drinking patterns have linear relationships with MetS and its components. Drinking quantity and binge drinking frequency were positively associated with MetS. On the other hand, drinking frequency was inversely associated with MetS in women, which may be attributable to its favorable effect on HDL cholesterol level. Although the risk of low HDL cholesterol decreased as drinking frequency increased, other MetS components changed adversely, so that frequent drinking cannot be said to prevent or relieve the risk of cardiovascular disease. Our results suggest that separate management of each component of MetS will be required to preserve cardio-metabolic health and that a healthy drinking culture that refrains from binge drinking should be established in the context of public health.


Introduction: YouTube is a free video-sharing platform, which is watched by residents or specialists in order to catch up on their skills, see new techniques, and have information. In this study, our purpose is to evaluate whether or not these videos are an appropriate educational source for surgeons by analyzing their quality and content, in an environment of reduced elective operations due to the COVID-19 pandemic.Methods: YouTube video search was performed by entering keywords such as CRS and HIPEC, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, cytoreductive surgery, and HIPEC. A total of 115 videos were found. Videos were divided into two groups as those containing operation videos and those that do not . And then, for evaluating operation videos, a scoring system was defined based on CRS + HIPEC steps as defined by Sugarbaker and video quality.Results: There were 45 operation videos and 70 videos of other content. The total number of views, number of views per day, and the total number of likes and comments were all significantly higher in the operation video group . No statistically significant difference was found in the median values of the number of views, likes, and dislikes; the number of views per day; the number of comments; and the dates of uploads within different video-scoring system groups.Conclusion: Our study shows that there is an increasing interest in CRS + HIPEC videos on YouTube. On the other hand, when the educational value of these videos that are receiving attention is considered, we believe it is not right to adjudicate due to the fact that the numbers are very low. General surgery residency is a long and wearing process. Varying among countries, mean labor hours are between 48 and 80 hours a week ,2. In TuYouTube is a free video-sharing platform visited by 95% of internet users actively, which started broadcasts in 2005 . UndoubtIn this case, could YouTube be a potential training platform for CRS + HIPEC  operation, which has high morbidity and mortality rates and long operation times? Peritoneal carcinomatosis is a condition that shows poor prognosis and low survival expectation, which may appear at many end-stage cancers. CRS was defined in 1930, followed by hyperthermic chemotherapy in 1977 . The perIn this study, we investigated the CRS + HIPEC videos uploaded to the YouTube platform. Our purpose is to evaluate whether or not these videos are an appropriate educational source for surgeons by analyzing their quality and content in an environment of reduced elective operations due to the COVID-19 pandemic.On October 14, 2020, a YouTube video search was performed by entering keywords CRS and HIPEC, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, cytoreductive surgery, and HIPEC. A total of 61 videos were found in CRS + HIPEC search, among which 71 videos were in cytoreductive surgery and HIPEC search and 57 were in hyperthermic intraperitoneal chemotherapy. Shared videos in each group were found in order to avoid repeats. A total of 118 videos were found. By taking the number of views into consideration, videos were sorted by view counts. Due to the possibility that new videos of the subject may be uploaded, our list of videos was saved as a playlist. This way prevented adding more videos to the study during the evaluation of the videos and statistical analysis.Videos were watched together by a surgical oncologist and a general surgery resident. Each video was evaluated for video quality, verbal expression, video language, length, step-by-step definition of the operation, the number of views and likes, subtitle availability, duration since the day of upload, and the number of comments. Comments of a surgical oncologist who knows the CRS + HIPEC procedure steps and a general surgery resident who is still on the learning curve and does not have sufficient knowledge of the procedure were noted. First of all, videos were divided into two groups as those containing operation videos and those that do not . And then, due to the fact that there is no standard method for evaluating operation videos, a scoring system was defined based on CRS + HIPEC steps as defined by Sugarbaker  and videInstitutional Review Board and Ethical approval were not received for the present study as only the common data open to public access were used.StatisticsData were analyzed using Statistical Package for the Social Sciences (SPSS) version 22.00 . Pearson chi-square and Fisher tests were used for evaluation of nominal data of each group, student’s T-test for scale parametric data, and Mann-Whitney U test for scale nonparametric data. One-way ANOVA , Kruskal-Wallis test, and posthoc multiple comparison (Bonferroni) test were used for the analysis of multiple groups. P < 0.05 was deemed statistically significant.A total of 118 videos were found containing keywords CRS + HIPEC, cytoreductive surgery and HIPEC, hyperthermic intraperitoneal chemotherapy in the YouTube search engine. Two videos were ruled out due to having a patient interview and one for containing only a pathology specimen. A total of 115 videos were evaluated; 39.1% of the videos included in this study (n = 45) consisted of operation videos, 27.8% were informative interview videos (n = 32), 10.4% were made of animation videos (n = 12), and 22.6% were presentations of congresses; 73.9% of the videos had voice narrative (n = 85), and 85.8% of them were in English. Only 59.1% of the videos had subtitles available (n = 68), and all of them were in English. The median number of views was 8177.70 (range 9-127637) and views per day were 7.98 (range 0.03-290). The distribution of the videos in the study according to their characteristics was shown in Table Videos were divided into two groups as those containing operation videos and those that do not . As to this setup, there were 45 operation videos and 70 videos of other content. Subsequently, the characteristics of each group were statistically compared. When the voice narration of the videos was compared, there was a statistically significant difference between the operation video group and the other group of nonoperational videos (p < 0.01). Both variables were higher in the group of nonoperational videos. However, when comments were evaluated, the operation video group had more comment rate, whereas 50 videos of the other group had no comments at all (p = 0.008). Due to the fact that none of the scale variables could pass the homogeneity and distribution test, It was evaluated with Mann-Whitney U test. The total number of views, number of views per day, and the total number of likes and comments were all significantly higher in the operation video group . Median values of dislikes and video lengths showed no statistically significant difference . There were 58 videos in the group below the median value and 57 in the other group above. Statistical analysis of both groups was performed. As a result, between the groups of the different numbers of views, there was no statistically significant difference in video duration, presence of voice narrative, video language, and subtitle availability. However, there was a significant difference between the groups when compared for video content and video resolution. Twenty-nine out of 45 operation videos were in the group above median value, whereas 42 out of 70 videos of other contents were in the group that was below (p = 0.011).Table In most professions in which hand skills are important and side instruments are used, it is possible to get ready for professional work-life using simulators or various training sets. However in the health sector, especially in the surgical field, these possibilities are limited due to the fact that working material is a human life. Lately, depending on the improvements on minimal invasive surgery, training sets or animal laboratories may be used for learning surgical techniques and use of surgical tools. However, these possibilities are not available for most of the surgical procedures, and most of the health personnel cannot acquire them. Therefore, surgery residents and specialists watch operational videos on YouTube and similar video platform sites. Also, some surgical societies suggest that the YouTube video platform may be a follow-up for surgery resident training. International Endohernia Society 2011 and 2015 Guide and European Hernia Society 2009 Guide tell that YouTube contributes surgeons a lot for totally extraperitoneal (TEP) procedure ,14.In the literature, there were no studies evaluating CRS + HIPEC videos in YouTube. On the other hand, we found many studies concerning laparoscopic bariatric surgery, laparoscopic inguinal hernia repair, laparoscopic cholecystectomy, and laparoscopic and robotic prostatectomy in YouTube. In most of these studies, authors included the first 120 videos when evaluating YouTube videos because in a study survey among internet users, it was found that most of the participants only investigated the first three pages . HoweverIn this study, only 45 (38.13%) of 118 videos that are included were made of operation videos. The exclusion rate was 2.54%. In a study by Yağız et al., videos containing operation videos were 82.5%, and the exclusion rate was 54.16% . The advA standard CRC + HIPEC procedure is six to seven hours long depending on the inclusion of peritonectomy and multiple organ resections. In a study that included 370 cases by Polanco et al., this duration was reported as 430 minutes . No doubCelentano et al. reported that 86.7% of surgery residents watch video platform sites of which 98% are YouTube . AccordiOne of the main reasons behind the increase in the number of views of surgical videos on YouTube is the learning curve. The term ‘learning curve’ was first defined by TP Wright in 1936 . It is dIn the popular video platform, YouTube, CRS + HiPEC operation videos draw attention even though they are low in numbers. This shows the interest in CRS + HiPEC operation videos. On the other hand, when the educational value of these videos that are receiving the attention is considered, we believe it is not right to adjudicate due to the fact that the numbers are very low. This handicap could be removed by uploading the videos containing operations of related societies and by professors who have the required information and experience on peritoneal surface malignancy to YouTube. Besides, these uploads may pave the way for new CRS + HiPEC studies associated with YouTube.


Facial wrinkles  appear as people get older. Wrinkle detection is an important aspect of applications that depend on facial skin changes, such as face age estimation and soft biometrics. While existing wrinkle detection algorithms focus on forehead horizontal lines, it is necessary to develop new methods to detect all wrinkles  on whole face. Therefore, we evaluated the performance of wrinkle detection algorithms on the whole face and proposed an enhancement technique to improve the performance. More specifically, we used 45 images of the Face Recognition Technology dataset (FERET) and 25 images of the Sudanese dataset. For ground truth annotations, the selected images were manually annotated by the researcher. The experiments showed that the method with enhancement performed better at detecting facial wrinkles when compared to the state-of-the-art methods. When evaluated on FERET, the average Jaccard similarity indices were 56.17%, 31.69% and 15.87% for the enhancement method, Hybrid Hessian Filter and Gabor Filter, respectively. Facial wrinkles are considered to be a facial feature, and appear as people get older . The chaOver recent decades, different approaches have been proposed to detect facial wrinkles . Loden et al.  are wrinAutomated wrinkle detection is an important process for some real-world applications. To bridge the gap in existing research, we evaluate the performance of the state-of-the-art wrinkle detection algorithm on the whole face. Furthermore, we propose to use an enhancement technique  to improThe rest of this paper is organized into the following sections: In an earlier work, Kown and lobo  studied Furthermore, other researchers attempted to develop an automatic wrinkle detection algorithm, which considered wrinkle detection as a line or ridge detection problem. Cula et al.  developeNg et al. ,6,11 proBatool and Chellappa  proposedMost of the wrinkle detection methods reviewed above focused on detecting horizontal lines in the forehead region. In 2017, Omaima et al.  proposedThis section describes the dataset preparation, the preprocessing steps and the wrinkle detection algorithms.Two datasets were used in this research: state-of-the-art face dataset (FERET) and a new Sudanese dataset.FERET dataset is one of the benchmark datasets used to assess the studies of facial analysis. Ng et al. used FERET in  to assesSudanese dataset was collected under natural light settings. It was taken in different environments under ambient light. The dataset consisted of 1287 images collected from 136 subjects . The age range is between 18 and 80 years old, inclusively. For each subject, there are 7 to 10 images with different facial expressions and poses. We distributed a questionnaire including personal data and smoking status, alongside a consent form to obtain permission to use participants’ photos for research purposes. The images were taken using Cannon EOS 600D, with flash turned on. For face detection, we use a freely available technique—Face++ detector . Face++ In this step, a face template or mask was used with ten predefined wrinkle regions with fixed coordinates for mouth and eyes . The masx, the Hessian matrix of s can be represented by:Facial wrinkles are considered to be an important feature of aging. Accurate wrinkle detection is a cornerstone in several image-based applications ,22. ManyTo determine the wrinkle shape and direction, eigenvalues  structure on dark (bright) background, so it can be represented as in Equation :(4)λi:={The vessel detection process was based on the brightness/darkness of vessel structure compared to the background. We can use a similar concept in wrinkle detection. Jerman’s et al.  enhancemTo enhance the algorithm, the measures of structural isotropy and anisotropy of diffusion tensors  which were used by Peeters et al.  can be aV can be enhanced to indicate elongated structures. The equation is modified by substituting Function V in Equation λp(sV is modified as represented in Equation (Using the output from Equation . FunctioEquation .(8)V=λ2s to 0.5, 1.0, 1.5, 2.0 and 2.5. We set the parameter In this equation response . FinallyA and B are the two binary masks representing manually annotated wrinkles and predicted wrinkles using computerized method). The result of experiments will be reported in the next subsections.To evaluate the performance of the wrinkle detection algorithms, we used Jaccard Similarity Index (JSI) or Jaccard similarity coefficient. Originally, JSI was introduced by Paul Jaccard . In 2015To evaluate the performance of the enhancement method, we compared it with two state-of-the-art methods—HHF  and GaboMore experiments were conducted to show how the enhancement method would perform in detecting the wrinkles in ten facial regions individually.To test the robustness of the enhancement method in detecting facial wrinkles, further experiments were conducted using 25 selected images from Sudanese dataset. The experiments were based on the state-of-the-art methods, HHF  and GaboUnlike previous wrinkle detection methods, which were used to detect forehead horizontal wrinkles ,6,13, weMore experiments for enhancement method were conducted to test the detection of wrinkles for each of the ten face regions taken individually. The result is shown in Although this experiment showed that enhancement method outperformed HHF and Gabor filter in detecting all facial wrinkles, more effort is needed to improve the enhancement algorithm to detect facial wrinkles. The method has some drawbacks: (1) It has a problem with illumination ; and (2) It generates false detection on hair, such as moustache and cheek. In this study, we tested the robustness of wrinkle detection methods on different skin type (mostly brown to dark skin), i.e., on our in-house Sudanese dataset. The evaluation showed poor results for all methods with an average JSI of 27.26%, 9.43%, and 17.6% for HHF, Gabor Filter, and enhancement method, respectively. Although the overall result was poor, HHF showed better results in detecting wrinkles for Sudanese dataset. We can attribute the bad result to the nature of the images, i.e. they were not taken under a controlled environment. In some worst case scenarios, the participants were exposed to direct sunlight. These factors are commonly known in computer vision tasks and affected the result for all the automated wrinkle detection algorithms.As mentioned in Furthermore, for the enhancement method, we have conducted empirical study for Existing wrinkle detection methods focus on detecting forehead wrinkles ,13, owin