IntroductionDelivering bad news to patients is an essential skill for physicians, which is often developed through patient encounters. Residents in our program participate in objective structured clinical examinations (OSCEs) on an annual basis to evaluate their skills in these scenarios. Our objectives were to develop an educational video and determine if an educational video provided to residents prior to OSCEs would improve performance.MethodsPrevious OSCEs were reviewed to identify best practices and to create a four-minute video highlighting the “do’s and don’ts” of delivering bad news. Residents in two post-graduate year (PGY) classes were randomized to watch the video prior to or after a standardized patient encounter. Three masked reviewers assessed resident empathy, attention, and understanding on 10 five-point Likert scales and assigned a total score . Hedges’ g was used to assess mean scores and effect size.ResultsA total of 17 residents participated in the evaluation: nine in the pre-OSCE video group and eight in the control group. Residents randomized to the video prior to the patient encounter had a mean score of 37.01 (SD=3.6). Residents randomized to the control group had a mean score of 35.38 (SD=4.85). Hedges’ g was 0.37 (95% CI: -0.59 to 1.33).ConclusionResidents randomized to the video group had a small increase in OSCE performance, which was not statistically significant. The novel video was helpful and addresses the need for a quick pre-assessment educational tool, though interns and graduating medical students may be a more appropriate target audience for instruction. Breaking bad news to patients is an essential skill for physicians. Without proper training, residents may develop inappropriate ways of delivering this information and may be ill-prepared to cope with the emotional repercussions . The disLearning professionalism begins in medical school , but theAt our residency training program, obstetric and gynecologic (OB/GYN) residents participate in objective structured clinical examinations (OSCEs) to provide a venue for resident evaluation in these scenarios. Residents interact with standardized patients, and the encounters are viewed by faculty to allow feedback to be provided to participants. A prior OSCE study at our institution demonstrated that residents engaged in minimum informed decision-making but did not address all of the communication elements necessary for informed decisions . AdditioToday’s learner is comfortable obtaining information in various formats, and the use of a video is an attractive teaching tool . Video hOur objective for this study was twofold. First, we sought to create a video of best practices to teach OB/GYN residents how to improve their skill with delivering bad news. Second, we sought to determine if this video provided to residents prior to OSCEs would improve performance on standardized patient assessments. Our hypothesis was that residents who provided information on best practices prior to a standardized patient encounter would score higher on OSCE scenarios that require residents to deliver bad news.This research was presented at the 2018 Council on Resident Education in Obstetrics and Gynecology (CREOG) and Association of Professors of Gynecology and Obstetrics (APGO) Annual Meeting, February 28 to March 3, 2018, in National Harbor, Maryland.Study designWe utilized a single-institution mixed-methods design of OB/GYN residents that combined qualitative and quantitative analysis. The qualitative aspect utilized direct feedback from our OSCE stations to create a novel video. The quantitative aspect evaluated the implementation of the video into future OSCE performance. This aspect was a randomized controlled trial where residents were randomized to the novel video (intervention) or no-video (control) groups prior to a formal evaluation of a scenario delivering bad news. IRB approval was granted by Indiana University.Educational video creationOur university OSCE stations are developed to assess residents’ technical skill and clinical acumen. Each post-graduate year (PGY) is assigned a dedicated day at our Simulation Center to be led through a variety of clinical and technical skills to allow for immediate feedback. One station for each PGY is utilized to assess a resident’s ability to deliver bad news to standardized patients. These OSCE encounters are video-recorded to allow for future playback and review.Intern OSCEs from the graduating classes of 2015-2018 were identified and reviewed (n = 40) . OSCEs iThe women identified specific behaviors as important do’s and don’ts of breaking bad news , which aThese identified behaviors , along wSubjectsParticipating residents were randomized via random number generator to watching the video before (intervention) or after (control) a standardized patient encounter in which they provided counseling following a miscarriage. Two classes of residents undergoing OSCEs formed our study group.OSCE evaluationIn our Breaking Bad News OSCE scenario, the standardized patient was in the first trimester, asymptomatic, and presented for a review of her ultrasound that noted a nonviable pregnancy. Female standardized patients were provided by the institution. These encounters occurred in a room designed to mimic an outpatient OB/GYN office with adequate equipment to allow for video and audio of the encounter to be captured. Prerequisite knowledge required by learners for this OSCE scenario included the definition of a missed abortion, the common causes of a missed abortion, the options available for treatment of a missed abortion, and the risk/benefits of the options available for treatment. The Breaking Bad News OSCE was one of 10 OSCE scenarios residents rotated through on one day. The duration of each OSCE scenario was 15 minutes for each resident, and each OSCE scenario was different ranging from assessing technical skills to knowledge. A debrief occurred after all the OSCE scenarios were completed. The staffing requirement for the Breaking Bad News OSCE included one standardized patient and one OB/GYN faculty evaluator. The standardized patient and the resident conducted the OSCE in the simulated clinical exam room while faculty reviewers performed the evaluation in a separate room via the video feed.Learner assessmentThere are numerous existing compilations of important behaviors and evaluation tools to assess attributes of professionalism ,27, and A total of 17 residents participated in the evaluation from two classes (PGY2 and PGY4). Residents were randomized into two groups: nine in the pre-OSCE video group and eight in the control group. There were more PGY2s assigned to the video group  and more PGY4s assigned to the control group . The average time to complete the patient interaction of delivering bad news was 12.24 minutes.The evaluation focused on Kirkpatrick’s pyramid level 2, Learning, and level 3, Behavior . LearninResidents randomized to the video prior to the patient encounter had a mean score of 37.01 with a standard deviation (SD) of 3.6. Residents randomized to the control group had a mean score of 35.38 with an SD of 4.85. Hedges’ g was 0.37 (95% CI -0.59-1.33). Residents randomized to the control group had a mean self-review of 4.13 (SD=0.23), 4.13 (SD=0.23), 3.13 (SD=0.4), and 4.25 (SD=0.25) for comfort, confidence, stress, and preparedness, respectively. There was no significant difference in self-reported scores with residents randomized to the video who had mean scores of 3.86 (SD=0.26), 3.71 (SD=0.26), 3.14 (SD=0.34), and 3.86 (SD=0.14) for the same categories.Residents randomized to the video group had a small increase in OSCE performance that was not statistically significant. Residents reported similar levels of comfort, confidence, stress, and preparation, with more than 90% reporting greater than 10 personal clinical encounters of breaking bad news.The delivery of bad news and difficult information occurs in all medical specialties ,6. ApproOur study involved the creation of a novel video to instruct residents on how to deliver bad news followed by an objective assessment of the video’s impact on OSCE performance. This qualitative feedback was instrumental in providing our trainees with feedback from patients in real-life scenarios . The vidLimitations of this study include a small sample size, conducting the study at one center, and analyzing results following one set of OSCEs, which all contribute to limiting the generalizability of the findings in this study. An additional limitation is utilizing an assessment tool without behavioral anchors. Future studies could include a larger sample size and multiple centers, utilize multiple sets of OSCEs for analysis, and include residents from multiple specialties  and from multiple PGY years. Additional improvements upon this study could include incorporation of behavioral anchors  and updating the educational video to prompt learner thinking and reflection.Numerous specialties in medicine in addition to OB/GYN require the ability to break bad news to patients empathetically and effectively. This OSCE scenario and preparatory video can be utilized for some specialties including family medicine and emergency medicine among others who may be faced with this situation. Other specialties could utilize the preparatory video and adapt the OSCE scenario to one that is more commonly faced in their field.Our study used a standardized patient encounter with an objective scoring rubric to examine the benefit of a four-minute video in PGY2 and PGY4 residents. Although participants who viewed the video prior to the OSCE scored similarly to those who were not provided the video, it is important to note that there were more PGY2s in the video group. Though the self-report of delivering bad news was high, it is likely that PGY4s would have more clinical experiences in delivering bad news compared to their PGY2 counterparts; thus, it is possible the video was more beneficial to this group with less experience delivering bad news and helped enable them to perform more like the more experienced residents in delivering bad news. Our sample size is too small to make definite conclusions regarding the impact of video by PGY; however, the video and OSCE assessment may assist those residents who have less clinical experience in delivering bad news. Additionally, interns and graduating medical students may be a more appropriate target audience for future study and intervention.Learning to break bad news to patients is an essential skill for physicians. Our study incorporated the available literature and focus group input to develop a concise video with best practices for resident training. Residents randomized to the video group had a small increase in OSCE performance that was not statistically significant. The novel video was helpful and addresses the need for a quick pre-assessment educational tool, though interns and graduating medical students may be a more appropriate target audience for instruction.


The worldwide shortage of medical-grade ventilators is a well-known issue, that has become one of the central topics during the COVID-19 pandemic. Given that these machines are expensive and have long lead times, one approach is to vacate them for patients in critical conditions while patients with mild to moderate symptoms are treated with stripped-down ventilators. We propose a mass-producible solution that can create such ventilators with minimum effort. The central part is a module that can be attached to CPAP machines and repurpose them as low-pressure ventilators. Here, we describe the concept and first measurements which underline the potential of our solution. Our approach may serve as a starting point for open-access ventilator technologies. Since the global vaccination process is still ongoing, treatments revolve around symptom control and life-sustaining measurements. Patients with COVID-19-related respiratory failures often require prolonged mechanical ventilation5. Such a treatment, however, cannot be provided due to a long-term worldwide issue: the shortage of medical-grade ventilators7. These costly devices have long lead times because of their complexity. Consequently, this shortage may continue to be one of few central issues during subsequent waves of the disease.The COVID-19 pandemic plunged many countries, such as Italy, Spain and the United States, into a health crisis due to the sudden demand for medical facilities, staff and equipment8. The lead time for each proposed design depends on the range of functionalities, cost and, more importantly, the available production facilities. One prominent approach focuses on machines that automatically compress and decompress bag valve masks13. Other groups pursue ventilator solutions that can be built from scratch with the expertise and the facilities from different industrial branches16.In response to the urgent need for ventilators, many designs were proposed to serve as life-sustaining measurements or to vacate medical-grade ventilators for patients in critical conditions19 and thus, there are potentially millions of CPAP machines around the globe that can be repurposed as stripped-down ventilators.In the presence of these developments, we propose a mass-producible solution that is built around continuous positive airway pressure (CPAP) machines. These home-level ventilators are commonly used to treat sleep apnea worldwide. Nowadays, many machines sit unused in householdsIP) and the positive end-expiratory pressure (PEEP), to assist or replace the patient’s breathing during the inhalation and exhalation phase,provide two well-defined airway pressure levels, i.e. the peak inspiratory pressure (Pset the respiratory rate in units of breaths per minute (bpm),set the I:E ratio, which is the ratio of the inhalation and the exhalation time, andallow patients to trigger and to cycle inhalation.CPAP machines generate and maintain a constant positive airway pressure to the patient. To cover the fundamental functions for mechanical ventilation, however, we need to:CPAP Apparatus Respiratory Life support), that can be attached to any CPAP machine and instantaneously repurpose it as a basic ventilator with minimum effort. We believe that our proposed solution can be used to treat patients with mild symptoms that do not require high-level pressures provided by medical-grade ventilators or to wean off recovering patients from the ventilator.Therefore, ventilation by means of CPAP machines requires a modification that regulates the constant pressure with time. We developed a module, referred to as CARL  for different ventilation parameters. As a representative patient model, we use an artificial lung (details in ‘Methods’).IP value, respiratory rate, and I:E ratio to 20 cmH2O, 20 bpm and 1:2, respectively. The ventilation curves for each ventilator are presented in Fig. IP value, while for machine u5 the plateau pressure approaches 19.4 cmH2O. The latter observation is due to a less powerful motor compared to the other machines. On the other hand, each ventilator can keep the PEEP value above 5 cmH2O which aligns with ventilation strategies for COVID-19-patients where a minimum airway pressure of at least 5 cmH2O must be maintained during the exhalation phase to stabilise the alveoli23.In our ventilator solution, the pressure is built up and maintained by a CPAP machine. Since each machine has its own feedback control system, the ventilation performance may vary with the machine model. To shed light on this, we test CARL with five different CPAP machine models while setting the PIP values, we repeated the same measurements but changed the PIP value to 15 cmH2O. The ventilation curves are presented in Fig. To investigate the impact of different P24. The acquired ventilation curves are comparable to the ones produced by already published mechanical ventilator solutions16 that vary with different sets of functionalities.Both measurements demonstrate that our CARL-based ventilator can generate two pressure levels to produce ventilation patterns typical for mechanical ventilationTime-related ventilation settings, i.e. the respiratory rate and the I:E ratio, are adjusted on CARL. In the following, we only consider the ventilation data taken with the machine u1 , since Fig. IP value and the respiratory rate. The acquired data for the airway pressure, flow, and volume as a function of time are presented in Fig. 26. Next, we vary the respiratory rate while keeping the PIP value and the I:E ratio fixed. The ventilation curves are presented in Fig. In our first test, we vary the I:E ratio while fixing the P16. As such, it should be possible to cover any range of values for the respiratory rate and the I:E ratio that are outlined in international standards28 or guidelines20.Both tests also show that the plateau pressure and the PEEP do not depend on the respiratory rate and the I:E ratio. This supports our previous finding that CPAP machines can quickly adapt to the sudden pressure and flow changes induced by CARL. Similar to other ventilation solutions, both ventilation parameters can be easily implemented in the code for the internal computer30. To support such events, the ventilator must be able to recognise the patient’s breathing effort, so that they can trigger and/or cycle the inspiration phase themselves. Our implementation relies on airflow monitoring which has also been implemented in another ventilation solution12. The ventilation curves in the case of spontaneous breathing during ventilation are presented in Fig. Patients who receive no sedation may breathe spontaneously during ventilation32. CPAP machines, on the other hand, usually operate while the patient is sleeping. As such, these machines rarely run for more than a few hours per day. To assess if an extended operation period can have an impact on the ventilation performance, we chose two CPAP machines and measure the ventilation curves after 72 h of operation. During this period, we observed no shutdown of the CPAP machine. Figure Depending on the patient’s health condition, ventilators must operate for a few days to weeks straightOur long-term tests reveal that CARL can operate for an extended period, while the performance of the CPAP machine may drop after a few days. Therefore, it is important to constantly monitor the ventilation curves and, if necessary, replace the CPAP machine to match the patient’s needs.2O while maintaining a minimum PEEP. Such ventilators may be used on COVID-19 patients with mild symptoms since critically ill patients require higher pressures which common CPAP machines cannot reach33. To determine the suitable clinical environments, e.g. critical-care or emergency and transport, and applicable clinical cases, an extended testing phase as part of pre-/clinical trials and reviews against international standards or guidelines are required. A crucial part of these examinations are tests against different lung parameter values such as lung compliance and linear resistance. Here, we tested our ventilator on a lung with lung parameters in the range found in ISO 80601-2-1227. Thus, additional tests are required at a later stage to determine the suitable clinical environment for CARL-based ventilators.The previous results demonstrate that our module CARL can repurpose CPAP machines to basic ventilators which provide ventilation pressures up to 20 cmH28. Critical-care ventilators, for example, require additional alarms that monitor the airway pressure, e.g. PEEP or high pressure, the delivered volume and airway obstructions27. So far, CARL has acoustic and visual alarms that monitor the operation of the motor and the connection to the pressure sensors. Protections against high pressures or airway obstructions are currently carried out by a valve unit that is part of CARL’s design (see Sect. 6.2). Given that the pressure, flow, and volume are continuously read out in CARL, we can implement in our software all pressure, flow and volume related alarms that are required for the targeted clinical environment.To contribute to the patient’s safety and address accidental/unintentional adjustments on the ventilator a set of alarms is essential. In commercial medical-grade ventilators, the set of mandatory alarms depend on the targeted clinical environment and are outlined in international standards such as ISO/TR 21954Since CARL-based ventilators are different to commercial medical-grade ventilators, additional training is necessary for the medical staff. For our ventilator solution, the medical staff must familiarise themselves with the CPAP machine and the CARL module. To reduce the training time required for CARL we use a clear and easy-to-use interface that allows constant patient monitoring and instant access to the ventilation settings, i.e. the respiratory rate and the two I:E ratios. While our basic ventilators require little time to set up and use, they should only be used by a trained staff member with ventilation expertise. This is because the performance of CPAP machines can vary with each model so that only constant monitoring and evaluation of the ventilation curves can lead to a successful patient treatment.Owing to CARL’s modular design, we can develop additional components to include more functionalities without interfering with the ventilator design. One potential component is a module to supply oxygen to the patient at a given oxygen level. This will also imply the addition of an oxygenation measurement device.Further adjustments to CARL’s design could be made to improve the infection control of the module. The design should allow the user to easily clean its surface within a reasonable time frame. In our case, this would primarily concern the components that are in the ventilation pathway. However, since these components are affordable and easy to produce, it may be safer to dispose and replace them instead. Owing to the working principle of CARL, our device could repurpose any continuous positive pressure machine to a basic ventilator. As such, CARL may be the starting point for an open-source ventilator solution. Such decisions, however, require testing the device carefully on animals or patients, which is beyond the scope of this report.The rapid dissemination of COVID-19 has led to a short-term shortage of ventilators worldwide. We believe that CPAP machines repurposed as stripped-down ventilators can help with the crisis in the short term. Our mass-producible solution could be used to vacate medical-grade ventilators for patients in critical conditions. However, in the worst case and after further development and regulatory approval, our solution may be used as a last resort to save the patient’s life.It is important to note that CARL must be rigorously examined and tested before it can be used on humans. This includes stress tests for both hardware and software, performance measurements under clinical conditions and a biocompatibility evaluation of all materials in the ventilation pathway.34.Our set of ventilation specifications is aimed at COVID-19 patients with mild symptoms as they may not require all functionalities provided by a medical-grade ventilator. A summary of the ventilation variables supported by our system is presented in Table In addition to the ventilation specifications, we also implemented functionalities in CARL’s design that ensure the patient’s safety during therapy and the safe operation of CARL. These functionalities are summarised in Table For the development of our module CARL, we aim for a mass-producible solution that can be manufactured worldwide. To fulfil this criterion, we developed a design that only uses easy-accessible hardware and electronic components. Our current design for CARL is presented in Fig. 2O at 20 cmH2O. To meet the set respiratory rate and I:E ratio during ventilation, the valve is attached to a computer-controlled motor. The patient receives air through a mask or an endotracheal/tracheostomy tube. Any excess air during the patient’s exhalation phase can escape through an exhalation valve that is placed between CARL and the patient.CARL serves as an intermediate module that we place in the ventilation pathway between the CPAP machine and the patient see Fig. . The air2O, e.g. in the event of a cough. The low-pressure valve guarantees that patients can inhale spontaneously in the event of a hardware or software failure. Additional ventilation parameters, e.g. the FiO2 value, can be extracted by connecting a patient monitor to the provided connector.We also designed a pop-off valve and a low-pressure valve to contribute to the patient’s safety. The former component makes sure that the airway pressure does not exceed 30 cmHTo measure the airway pressure and the flow, we use a flow sensor  that is connected to two implemented pressure sensors . The flow data is evaluated to determine the ventilation volume and to trigger and to cycle inspiration. As such, we can continuously monitor and evaluate the patient’s breathing behaviour during mechanical ventilation.millis, which returns the time that has passed since the program has been started35. After approximately 50 days, the time goes back (rolls over) to zero, which may cause timing issues during ventilation but is accounted for in our code.To comply with safety precautions while in operation, all electronic parts are protected by a professional casing. We use an Arduino Uno and an Arduino Nano to control all electric components in CARL. To implement the ventilation modes in Table The use of clear labels is essential for the safe use of CARL by the medical staff. To achieve this, all descriptions use standard terms that are recognised by qualified medical personnel. Figure 2O36. Since such sensors are mass-produced, their performance may vary with each product. Because of this, we must validate and calibrate all our measurements with an independent system. Here, we use a system that consists of a pneumotachometer  attached to a heater control  and a DC bridge amplifier . To acquire and evaluate the data from this setup we use the Embla RemLogic Software. For the calibration, we compare both data and adjust for systematic differences so that our data from the sensor matches the one from the external system. A representative result is presented in Fig. CARL uses accessible pressure sensors to monitor the pressure and the flow that are different to those implemented in medical-grade ventilators. For the sensor used in this study, the accuracy at room temperature is reported as 1 cmH37.To release the excess gas during ventilation, we use an exhalation valve  with a microfilter attached to it. The filter reduces the concentration of released air contaminants in the environment and thus, the overall infection risk for the medical staff. As a patient model, we use an artificial lung  that has a reported compliance and linear resistance value of 16 In this study, we use five different CPAP machine models which are summarised in Table


Olive oil is recognised for its beneficial effects on human health, mainly due to it containing oleic acid (a monounsaturated fatty acid), whereas fats of animal origin or margarine, which are often used in recipes for biscuit production, contain mainly saturated fatty acids. The aim of this study was to evaluate the shelf-life and physicochemical properties of biscuits and of the fats contained in original recipe Italian Cantuccini biscuits (50% cow’s butter and 50% margarine). Additionally, the sensory properties of the biscuits were evaluated, including their colour, appearance, taste, flavour, texture and overall acceptability. At the same time, the fat composition of the original recipe was also modified to contain 30% cow’s butter and 70% extra virgin olive oil, in order to replace an aliquot of the saturated fatty acid content with unsaturated fatty acids, in particular with one monounsaturated fatty acid, oleic acid. Colour (CIELab), water activity, relative humidity, hardness and fracturability analyses were conducted on Cantuccini biscuits. Colour (CIELab), free acidity, spectrophotometric characteristics, DPPH assay and fatty acid methyl ester (FAMEs) analyses were conducted on the fat extracted from Cantuccini biscuits prepared from both the original and modified recipes. The global biscuits market is segmented by category into sweet biscuits and crackers and savoury biscuits. The global market was evaluated at USD 106.232 billion in 2020, and it is estimated to reach a compound annual growth rate of 4.97% during the period 2021–2026 [Cantuccini are traditional sweet biscuits originally from Tuscany  but now found throughout Italy. They are dry biscuits that are filled with almonds, which are made by cutting slices of dough while still hot, before being the dough slices to the oven for a few minutes to reach their final consistency.Cantuccini have a European Protected Geographical Indication (PGI) , which iLipids in bakery products play a fundamental role from both technical and edible point of views. Lipids used in the bakery industry are oils or fats, which are respectively liquid or solid or semi-solid at room temperature. The differences in physical consistency are due to the triacylglycerol composition and in particular to the fatty acids and their melting points. Saturated fatty acids are solid or semi-solid at room temperature, whereas unsaturated fatty acids are liquid. The shorter the chain length and the lower the number of double bonds, the lower the melting point. Fats are easier to transport and less susceptible to oxidation than oils. At the same time, saturated fatty acids (SFAs), which are widely present in fats, and cholesterol  are considered responsible for cardiovascular diseases . The lipFrom an edible point of view, the fat in biscuits is important for its nutritional value, for its tendency for oxidation and for the consequential radical formation. From a technical point of view, when fats are mixed with flour that has not yet been hydrated, particles of fats wrap around the particles of flour, reducing the dough’s elasticity . High elIn addition, fat has a lubricating action, which prevents the product from sticking to baking trays and causes the melting sensation when a biscuit is eaten.To date in the literature, there have been no studies on the physical–chemical–sensory evolution of Cantuccini during storage. Scarce information exists on biscuits  and cookThe aim of this paper was to study the shelf-life of Cantuccini biscuits produced using the original recipe containing only cow’s butter and margarine, as well as the effects of partial shortening replacement with extra virgin olive oil over one year’s storage.2; weight per pack: 8.05 g; heat sealing: both sides; oxygen barrier: very low >150; water vapour barrier: high (0.50–3.00); thermal treatment: none; composition: outer layer: COEXPP 30 μm; inner layer i.e., side in contact: COEXPP BL MAS 40 μm.Each package contained 35 biscuits weighing 200 g in total. For this experiment, biscuits were made using two recipes, which differed only in the type of fats or oils used. In the first  recipe, 7% fat was used , at a ratio of 50% cow’s butter to 50% margarine. In the second (modified) recipe, 11% fat was used , at a ratio of 30% cow’s butter to 70% extra virgin olive oil. This modified recipe was applied after testing the consistency and pleasantness of the Cantuccini. This ratio was applied so as not to distort the type of product and to provide the right compromise between tradition and innovation. The shortening reduction led to the need for an increase in the EVOO to maintain the original characteristics of the biscuits as much as possible. The technical data on the packaging were: duplex laminate; width: 410 mm; cut off: 285 mm; thickness: 74 μm; material identification code: PP 5; core diameter: 76 mm; outer diameter: 280 mm; unit weight: 68.9 g/mThe original recipe (OR) for Cantuccini biscuits contained 50% cow’s butter and 50% margarine. The modified recipe (MR) contained 30% cow’s butter and 70% extra virgin olive oil. Sugar, margarine, butter and honey were placed in a mixer. The ingredients were mixed until smooth. At this point the eggs, baking powder and flour (00 type) were added. Finally, when the mixture was homogeneous, the whole almonds were added. The dough was kneaded until it was homogeneous, without lumps and of a good consistency. The dough was left for twenty minutes. At this point, pieces of dough weighing 2 kg were passed under the leveler before being cut into small pieces, which were placed in the baking pans and baked at 200 °C for 20 min. The Cantuccini were removed from the oven and cooled to room temperature before packaging. The hardness and fracturability of Cantuccini were determined using a texture analyzer  equipped with a 25 kg load cell and a three-point bending rig (HDP/3PB). The parameters of hardness and fracturability were calculated as absolute values.L*, Chroma a* (a*) and Chroma b* (b*). If a colour is expressed in CIELAB, L* denotes lightness, a* defines the red/green value and b* the yellow/blue value. In this experiment, colour determination was conducted on both the external (the top of the biscuit) and internal sides (the side of the cut) of Cantuccini biscuits.Colour was determined using a colourimeter  measuring Aw is the ratio between the vapour pressure of a food system when it is not influenced by the environment (Pv) and the saturation vapour pressure of distilled water (Pa) in the same conditions . The aw The RH (moisture content) was determined according to the method proposed by , with heA 20-member sensory panel was involved (ten men and ten women aged 19 to 60 years). The panelists were trained to consider six attributes, namely colour, appearance, taste, flavour, texture and overall acceptability. Each attribute was evaluated on a 10-point hedonic scale (1–10) ranging from 10 (like extremely) to 1 (dislike extremely) for each characteristic and with 5 representing minimum quality. The test was conducted in a sensory laboratory with individual booths and Cantuccini biscuits were given in white plates in a room prepared as suggested by ‘Sensory Analysis—General Guidance for the Design of Test Rooms’ . The panColour expressed the degree of toasting. Appearance defined the shape of the biscuit. Taste and flavour defined the freshness of Cantuccini. Texture defined the crunchiness and overall acceptability was the sum of the previous five attributes. The sensory analysis was conducted prior to inform the panelists with regard to the Cantuccini composition.n-hexane as the extracting solvent. Lastly, the solvent was evaporated using a Rotavapour apparatus under vacuum at 25 °C and fat was stored until analyses [Firstly, the almonds were separated from the biscuits and then reduced to a powder. Secondly, the lipid fraction was extracted from the powder of biscuits using a Soxhlet apparatus with analyses .L* (brigthness) ranges between 0 (black) and 100 (white); a* ranges between −90 (green) and +90 (red); b* ranges between −90 (blue) and +90 (yellow). The chroma was calculated using the formula discussed by Pathare et al. [A Minolta Chroma Meter CR-400 instrument and a Minolta transparent (base and side) special glass container  with a cylindrical shape was used. One centimetre of fat was added to the glass container and the colour was determined. A further 1 cm was added and the colour was determined again. These two measurements were conducted in triplicate. The CIELab scale was used: e et al. .A 1 g aliquot of the lipidic fraction was dissolved in a 50 mL ethanol/diethyl ether (1:1), after which titration was conducted with a 0.1 N NaOH solution. The results were expressed as g oleic acid/100 g  [w/v) and the solution was read at 232 nm, 266 nm, 268 nm and 274 nm, in a double-ray Agilent spectrophotometer model 89090A   [The lipid extract was dissolved in iso-octane and a 1% (nnex IX) .2 from Perkin Elmer  using the method proposed by Kalantzakis et al. [v/v). Then, 0.25 mL of diluted oil was added to 2.25 mL of a 10−4 M DPPH● solution, which was previously prepared with ethyl acetate. Thus, the absorbance of the mixture was immediately measured at 515 nm (abs t0) and after 30 min of shaking and incubation in the dark (abs t30). The % of inhibition was calculated as follows: ((abs t0 − abs t30)/abs t0)) * 100. The radical scavenging activity (% of inhibition) was compared with a Trolox calibration curve and results were then expressed as TEAC values (μmol TE∙100 g−1 of fat extracted).The DPPH assay of the extracted fat was performed without extracting antioxidant compounds from the fat. It was conducted in an UV/Vis Spectrometer λs et al. , modifieAn aliquot of the lipid fraction was methylated using the annex XB method A . Gas chr2 values and r values were obtained using Excel 2010 software. The t-test was calculated at the 95% confidence interval. Analysis of variance (one-way ANOVA) and Tukey’s tests were performed to determine the significance of differences. A p-value < 0.05 was set as the significance level using SPSS software version 17.0.All analyses were carried out on three batches of Cantuccini biscuits, each one produced on a different day. For each batch, two replicates were conducted, each one from a different package. In brief, each result was the mean of six analyses. Means, standard deviations, RL* was highest in Cantuccini prepared with the original recipe; thereafter, the highest lightness value was found in the Cantuccini prepared with the modified recipe, showing a tendency to clear with time in biscuits prepared with 70% EVOO. The same initial trend but for a 4 month storage period was found for L* inside the biscuits  and b* (p < 0.01) in the external measurement of the modified recipe ; in addition, on the external side of the MR Cantuccini, a decreasing tendency in a* values was found  (The < 0.001) . These v< 0.001) . The chr< 0.001) .L* increase (36 d), a subsequent decrease until 144 d and a final increase to 180 d; in the same study, in agreement with our results, a substantial increase in the b* value was found during the first 108 days, with a subsequent decrease up to 180 d.De Morais et al.  studied Moisture content plays a fundamental role in the manufacturing process of bakery products, including Cantuccini biscuits; furthermore, it influences their flavour, fragrance and consistency.p < 0.001), whereas RH in MR Cantuccini varied from 3.55 (T0) to 4.56 (T12), with a significant 28.5% increase (p < 0.001) in the same storage period (v/v) of air included in the package at the time of sealing; (ii) a little vapour exchange also occurred during the one year of storage with the external atmosphere because the water vapour barrier of the packaging material used by the producer was high but not very high. It has to be pointed out that normally Cantuccini are consumed within 3–4 months of production, and in both the studied recipes RH showed low increases during the first six months, after which the increases were more evident  were confirmed by findings of Robertson , who foup < 0.001), whereas in MR Cantuccini, the values moved from 0.223 (T0) to 0.390 (T12) (p < 0.001). Data for aw were found to be correlated with RH values as follows: R2 = 0.5636 and r = 0.7507 for OR; R2 = 0.8527 and r = 0.9234 for MR. As with RH, for aw the values also increased slightly for the first 6 months and more consistently from the 6th to the 12th month.The aw showed very high and significant increasing trends in both recipes b. In detThis is in agreement with the findings of Hough et al. , who fouThe modified Cantuccini recipe contains reduced amounts of both the RH and aw a,b. ThisThese values were lower than those found in Amaretti cookies (0.64–0.80) that were individually packaged in a high water vapour barrier film and stored for 120 days . The incTexture is often considered by consumers at a subconscious level. The evaluation of the texture is not immediate because consumers often concentrate initially on flavour ; howeverCrispy is defined as, “A dry, rigid food, which when bitten with the incisors, fractures quickly, easily and totally, while emitting a relatively loud, high-pitched sound”, whereas crunchy is defined, “A dense-textured food, which when chewed with the molars, undergoes a series of fractures while emitting relatively loud, low-pitched sounds” .p < 0.001) and 1.54 times in the MR Cantuccini (p < 0.05)  a. The ha < 0.05) a.Hough et al. studied different bakery products and found a negative correlation between aw and texture, as well as differences in relations to the biscuit composition and the type of flour . Piga etFracturability value was determined as the distance taken by the probe until the point of fracture.p < 0.05) for the MR , and the higher the RH the lower the hardness . Similarly, in the MR Cantuccini, the higher the aw the lower the hardness , and the higher RH the lower the hardness .Two of the most important parameters influencing hardness and fracturability are aw and RH, which were found to be inversely correlated with hardness. These data are explained by the Pearson test and t-test. In the OR Cantuccini, the higher the aw the lower the hardness (Rp ≤ 0.05) for formulations containing potato and corn starch with respect to biscuits prepared without eggs and without carob syrup. These results were explained by the looser matrix formation in potato and corn starch formulations, which contained lower levels of proteins [p < 0.01) between fracturability and firmness (r = 0.973), consistency (r = 0.933) and maximum strength (hardness) (r = 1), with a moderate correlation (p < 0.05) between fracturability and stiffness (r = 0.405) [Findings from other authors reported higher fracturability values (proteins . Torres-= 0.405) .The sensory characteristics analysed by the panelists decreased during storage, although with different trends for OR Cantuccini and MR.The panelists preferred the colour of OR Cantuccini for the first 8 months of storage, whereas the colour of MR Cantuccini was better evaluated from T10. At T12, the colour of the OR biscuits was considered to be of minimum acceptable quality a.OR Cantuccini obtained the highest scores until T4 and were equally evaluated from T6 to T10, whereas at T12 the biscuits prepared with EVOO were preferred b.The taste and flavour of OR Cantuccini were preferred in the first period of storage, although the panelists gave the same scores at T10 and T12 for taste and the same scores at T8 and T10 for flavour, with a preference for the flavour of OR at T12 c,d. The We can speculate that the EVOO in the recipe preserved or extended the Cantuccini shelf-life and consequently the sensory properties. Our observations are in agreement with the findings of other authors, who studied the addition of phenolic extracts from olive leaves and olive mill wastewater to gluten-free breadsticks and found an amelioration in the physical–chemical–sensory properties of these bakery products .Sensory properties and shelf-life were found to be related. In a study conducted on the shelf-lives of 3-month-packaged biscuits, other authors found no substantial variation in the first 2 months of storage and only slightly decreased scores for certain sensory attributes  after 3 months of storage . L*) was always highest in the OR Cantuccini, which showed a constant and significant decrease (p < 0.05) from 25.51 (T0) to 23.90 (T12). The same decreasing behaviour was measured in MR Cantuccini from 24.80 (T0) to 21.69 (T12) (p < 0.001). These values describe a browning of the fat during storage in both recipes.The colour values for Cantuccini fats are depicted in the a* values for the first 8 months and at the same time an increasing trend from 0.50 (T0) to 0.87 (T12) and a 74% increase in red colouring after 12 months (p < 0.001), whereas the a* values in the fat of OR Cantuccini increased from 0.45 (T0) to 1.19 (T12) with an increase of 164% (p < 0.001). The a* values showed constant reddening of the fat for both recipes during the shelf-life. The b* values of OR Cantuccini moved between 3.26 (T0) and 5.08 (T12), with yellowing of the fat during the 12 month storage period, whereas the fat extracted from MR Cantuccini showed an inverse and decreasing behaviour from 5.07 (To) to 4.28 (T12) with a tendency toward blue colouring.The fat colour of MR Cantuccini produced the highest Chroma testing is applied to evaluate the degree of difference of a hue in comparison to a grey with the same lightness. The higher the chroma values, the higher the colour intensity of the samples as perceived by humans . In bothb* and chroma values were significantly influenced by the interaction between flour and fat (p < 0.05), with the most intensive sample being prepared with oats and olive oil [Other studies have shown the influence of fat on colouring. Goubgou et al.  studied live oil .p < 0.01) in fat extracted from both OR and MR Cantuccini, with a tendency to increase with storage . Similarly, free acidity increases were found in six different biscuits prepared with six different cereals and stored with two different packaging materials and for three months [Daglioglu et al.  studied e months .The DPPH assay is commonly applied to many matrices to test their antioxidant capacity ,53,54.−1 fat) in fat from MR and 164.15 (μmol TE·100 g−1 fat) in fat from OR . During 12 months’ storage, a continuous reduction was found in the antioxidant activity measured with the DPPH assay . After 12 months’ storage, the antioxidant activity levels were 168.75 (MR) and 140.58 (OR) μmol TE·100 g−1 fat, respectively, i.e., a decrease of 20.73% from T0 to T12 for the MR and a decrease of 16.77 in the same period for the OR , the DPPH value was 203.74  than in the MR fat . This was due to the high spectrophotometric K232 indices of 2.914 and 2.062, respectively, for cow’s butter and margarine as a consequence of the high conjugated diene content. At the same time, the K268 indices were also high for both cow’s butter (0.726) and margarine (0.751) in relation to the conjugated trienes.p < 0.001), whereas the K232 value in the MR fat was 3.22 after 12 months’ storage (57.08% more than T0) (p < 0.001); this meant that the relative increase was more or less 2 times higher in the fat from the MR, although the absolute values were similar in fats from the OR and MR, especially in the last 4 months of storage  , whereas the K268 value in the MR fat was 0.64 after 12 months’ storage, i.e., only partially different from the T0 value b.Additionally, the high K268 indices were due to the fats used in OR Cantuccini, namely 0.751 for cow’s butter and 0.726 for margarine, as a consequence of the high conjugated triene content.Schafer-De Martini Soares et al.  studied Taralli (a savoury biscuit) prepared with extra virgin olive oil, olive pomace oil and refined palm oil, and found that extra virgin olive oil always showed the lowest values for both indices. This confirms our results regarding K268, for which extra virgin olive oil showed a reduction in the formation of the secondary products of oxidation.The ΔK value was higher in fat from OR than in fat from MR at all sampling points  c. It is The Trade Standard applied to olive oil by the International Olive Council  and the The FAME composition of the OR Cantuccini showed 36.21–38.60% of SFAs , whereasThe changes in fatty acid composition were related to alterations during storage, which were found to be due to the initial fat content, initial water content and storage duration . At the Culetu et al.  found diThe complete replacement of margarine and the partial replacement of butter with extra virgin olive oil in the original Cantuccini biscuit recipe led to improvements in water activity, relative humidity, hardness, K270 values, DPPH assay results and acidity, whereas worse results were found with regard to K232 and ΔK values. This means that the use of extra virgin olive oil in the recipe, in many cases studied in this work, improved the physical and chemical properties of biscuits but worsened the parameters related to the secondary products of oxidation (K270). The Cantuccini biscuit colour was instrumentally evaluated and found to be strictly related to both fats and EVOO and to the length of storage. The fatty acid methyl ester compositions varied dramatically and the use of EVOO increased the unsaturated fatty acid content, in particular monounsaturated fatty acids, with oleic acid being the prevailing compound. The sensory analysis showed an expected worsening of the biscuit quality but good acceptability of Cantuccini prepared with 70% EVOO. Extra virgin olive oil can be applied to prepare functional products that maintain the physical–chemical–sensory properties of Cantuccini.


This study explored the internal and external factors affecting the first drinking experience during Korean adolescence. To achieve this, we collected 34 cases revealing specific drinking experiences during adolescence in Alcoholic Anonymous (A.A.), Korea. The collected data were analyzed using a qualitative case study method, and the analysis focused on the internal and external factors influencing drinking in adolescence. As per the results, internal factors that influenced drinking in adolescence were “curiosity” and “elevated mood and stress relief”, and external factors were “family”, “friends”, “older friends at school”, “neighbors”, “Korean tradition of alcohol making”, “workplaces that encourage alcohol consumption”, and “a generous drinking culture.” Based on these findings, we suggested several practical alternatives, such as a stringent alcohol punishment system, government-led campaigns to overcome the generous alcohol culture, monitoring the drinking status of working and intern youths, and using local crime prevention guards to curb youth drinking. In future research, it is necessary to quantitatively verify the results of this study to develop theories related to adolescent drinking behavior. Excessive drinking causes several problems. Individuals who drink excessively may experience physical and mental problems and accidents such as drunk driving . AdditioThe social service sector deals with alcohol abuse problems in all age groups, but we need to pay more attention to adolescents’ drinking problems. This is because adolescent drinking behavior can lead to other delinquent behaviors . In manyAdolescence is also a period of rapid physical growth; the risk of damage to organs such as the brain, liver, and kidneys, and sexual dysfunction due to alcohol consumption is higher than that in adults . ConstanTo better understand and intervene in the drinking experience of adolescents, the individual and the surrounding environment must be considered together. Ecological systems theory emphasizes the understanding of interactions between humans and the environment  and regaDemographic factors such as gender and age can be considered internal factors affecting adolescents’ drinking. In general, the drinking rate in men is higher than that in women, and it increases with age ,8,16,17.Environmental factors include family, peer group, school, and culture. Reportedly, relations with family and family history affect adolescents’ drinking habits. Dysfunctional interactions within the family, such as conflicts, neglect, and inconsistent parenting attitudes have been reported to be closely related to drinking in adolescents ,27. PareBecause adolescents are influenced by peer groups, drinking and peer pressure are important variables predicting adolescents’ drinking ,22. PartSociocultural factors have also been reported as predictors of drinking in adolescents. It was found that the price of alcohol and the drinking rate of adolescents were inversely proportional , and thePrevious studies presented above suggest that various factors influence adolescents’ drinking. However, they have some limitations. First, prior studies did not address the causes of alcohol initiation in adolescents. Additionally, existing studies mainly analyzed quantitative data to identify factors that influence adolescents’ drinking, so they did not reveal specific drinking contents and experiences. To overcome these limitations, we focused on why the first drinking experience occurred in adolescence. Therefore, we collected cases related to the first drinking experience of adolescents and tried to determine the internal and external factors that act as the first drinking trigger. Through this process, it is possible to contribute to the establishment of prevention strategy by specifically revealing the drinking pathways of adolescence.We used a purposeful sampling method for data collection because it was necessary to select cases that fit the purpose of the study and to explore adolescents’ first drinking experience. We collected alcoholic recovery notes published from January 2015 to March 2021 in Alcoholic Anonymous (A.A.), Korea, to identify cases of adolescent drinking experiences. A total of 236 cases of actual experiences were secured, and among them, 34 cases were analyzed as they contained first alcohol experiences during adolescence in detail. In our data, alcohol consumers in adolescence drank various types of alcohol between the ages of 5 and 18 and were influenced by internal and external factors such as curiosity and recommendations from friends .We used a qualitative case study method to analyze the collected data . QualitaTo conduct qualitative research, the rigor of research and ethical issues should be considered together. Because this study analyzed secondary data called casebooks, ethical issues that might have otherwise risen during interviews or observations did not arise. Therefore, we focused on securing the rigor of the study. To do so, we used strategies such as triangulation, peer support groups, and audit trails . First, As a result of the analysis, two internal factors were found, including “Curiosity” and “Elevated mood and stress relief”. External factors were found, including “Family ”, Friends”, “Older friends at school”, Neighbors (adult)”, “Korean tradition of alcohol making”, “Workplaces that recommended alcohol” and “Generous drinking culture”.Curiosity acted as an internal factor in that those who drank alcohol in adolescence drank out of curiosity. As suggested by previous studies, curiosity serves as a motive for drinking alcohol during adolescence ,22. Some“I remember drinking for the first time when I was in the freshman of high school. I secretly drank out of curiosity with my friends, and when I became an adult, I drank every day with my acquaintances.” (case 1)soju.” (case 2)“The first time I drank alcohol was when I was 17 years old. At first, I started drinking beer out of curiosity, and after a few months, I drank “The first time I drank alcohol, I was in the freshman of high school, and I drank out of curiosity. After drinking, I felt like I owned the whole world, and I felt a sense of freedom from not having to hide myself anymore.” (case 3)Those who experienced drinking alcohol in adolescence did not drink simply out of curiosity. Alcohol served as a tool to elevate their mood and relieve stress. Previous studies have also noted that emotional factors such as emptiness, emotional instability, thrill-seeking behavior, and impulse control problems are related to drinking in adolescence ,23,25. I“After drinking, I felt like I owned the whole world, and I felt a sense of freedom from not having to hide myself anymore. I was afraid of people because I had an introverted personality. However, I was not afraid anymore.” (case 3)“When I drank, I kept smiling and felt very good, and I felt my usual introvert personality became bold.” (case 4)“The first time I drank alcohol was when I was 16 years old. A relative ran a liquor dealership in the neighborhood, when I had the time, I went to work there. There, I learned that drinking made me feel good, and I started to drink more and more.” (case 5)“I had a conflict with my friend in middle school, but I was upset that I could not resolve it and could not get angry properly. I suffered from lethargy, and my academic performance decreased. So, I drank for the first time when I was in the sophomore of middle school.” (case 6)“When I drank alcohol, my nervousness, anxiety, and frustration seemed to disappear. Alcohol cured me faster than medicine.” (case 7)“When I was 16 years old, my close friend died, and my parents broke up. I was very shocked. So, that’s when I started wandering. I drank with my friends for the first time, and alcohol caused my stress, irritation, depression, and anxiety to disappear.” (case 8)The old Korean maxims have a saying, “Drinking should be learned from adults,” meaning adults in the household teach drinking etiquette, which shows the family’s influence on adolescent alcohol drinking. Of course, existing studies also point at “family” as a factor in drinking alcohol in adolescence. However, previous studies have shown that dysfunctional family relationships  lead to drinking ,26,27,29“I started drinking in earnest when I was a sophomore in high school. A relative taught me how to smoke cigarettes and drink alcohol.” (case 9)“I had a good relationship with my dad, and when I was 5, my dad gave me the leftover alcohol, and I drank it pleasantly.” (case 10)“My family had many Korean ancestral rites, so I was lucky as I drank alcohol during Korean ancestral rites every time. Family who saw me drinking thought I was cute, so they recommended me to drink more.” (case 11)“I first started drinking when I was 15 years old, and my grandfather suggested that I drink.” (case 12)In Korea, a friend refers to a person of the same age. In Korean culture, where age is important in relationships, people tend to communicate more comfortably with other people of the same age. In previous studies ,21,22, ““When I was in the sophomore of high school, I drank with my friends in the mountains in the neighborhood, calling it a rite of passage.” (case 11)“When I was 18 years old, I drank a large amount of alcohol with my friends for the first time.” (case 13)makgeolli with my friends during the winter vacation and vomited a lot. I rarely talked to my friends when I did not drink.” (case 14)“When I was in the sophomore high school, I drank soju with my friends at a park in the village and drank yogurt as a snack.” (case 15)“The first time I drank alcohol was in the fall when I was 15 years old. I had three bottles of “I drank for the first time when I was in the sophomore of middle school. I hated studying and naturally hung out with juvenile delinquents.” (case 16)“I drank for the first time when I was in the junior of middle school. I liked to play with my friends and hated studying.” (case 17)“When I was in the junior of high school, I drank with my friends for the first time. I felt that the draft beer I drank with my friends for the first time tasted worse than coke, but I drank it at once seeing my friends drink.” (case 18)The recommendation and coercion of older friends at school also served as a trigger for drinking alcohol during adolescence. As mentioned earlier, in Korean society, where age is important for the formation of relationships, high and low authority relationships are formed around the same age . Particu“I did not think that the drinking habits I learned from older friends in middle school would be the trigger for alcoholism until I was 44 years old.” (case 19)“The first time I drank alcohol was when I was 15 years old. I went to my friend’s house and drank the beer that my friend’s sister bought for the first time. Dancing drunk all night made me feel better.” (case 20)“The first time I drank alcohol was when I was in the sophomore of middle school. My friends and I drank because older friends at school told us to come to drink.” (case 21)makgeolli recommended by older friends at school in celebration of the freshmen.” (case 22)“The first time I drank alcohol was when I was in college, and I drank “When I was in the second year of middle school, older friends at school ordered me and my friends to buy alcohol. Older friends started drinking, then assaulted me and my friends who did not drink with the club, forcing us to drink.” (case 23)Along with family, friends, and older friends at school, neighbors also influence alcohol drinking in adolescence. Adolescent alcohol users drank alcohol as recommended by local adults that they were close to . These examples specifically illustrate the government’s findings that 24.6% of the 3595 teenagers surveyed were recommended to drink by adults outside their families at restaurants . Althougmakgeolli. Alcohol overwhelmed my small body and immature mind.” (case 4)“I had my first drink when I was in elementary school. The man who owned the laundromat offered me a shot of “When I was a senior in high school, a local man gathered the kids and made them drink. I drank until I was blacked out.” (case 6)makgeolli were excited and poured into my bowl. I was hungry and thirsty, and the makgeolli was just the drink and food for me.” (case 24)“I first drank alcohol during the autumn harvest of rice farming in 12 years old. The elders who had been eating In the past, many families in Korea made their own alcohol . Althoug“When I was a middle school student, I stole alcohol, which my mom soaked from home and drank. My face burned red, and an indescribable ecstasy came to me, and I drank whenever I had a chance.” (case 25)makgeolli with sugar. I drank it secretly, and every time I drank it, I would wander around and fell asleep.” (case 26)“I saw my grandmother drinking after working on a hot summer day when I was in elementary school. She drank homemade Most students who drop out of school or attend vocational high schools find employment in early jobs or internships. During this process, people encountered alcohol . As they watched adults working together drink alcohol, they naturally imitated it, and also drank at the recommendation of adults. This suggests that even adolescents can be easily exposed to alcohol if they live together in a space centered on adults. Additionally, like in case 31 that “Even if you are young, you are adult when you are work!”, the possibility of drinking at work increases if you are recognized as an adult.“When I was a senior in high school, I went on vocational training. It started then. I was exposed to alcohol easily because I was a student and worker. Alcohol was my friend in difficult situations where I had to work overtime.” (case 27)haejangsul  in a workplace restaurant in the morning. I drank too much a day ago, but after drinking the haejangsul, I felt like I would live.” (case 28)“I decided to give up on graduating from high school and learned vocational skills. As I was working, I always saw people drinking the “At a young age (from a senior high school), I ran away from home and boarded a tuna fishing ship. Then, for the first time on a ship, I learned to drink liqueur.” (case 29)“When I was 16, I dropped out of school and got a job at a factory. While hanging out with seniors, I started drinking for the first time at the age of 19.” (case 30)“At the age of 17, I had to drop out of high school after several months due to difficult family conditions. I got a job as a deliveryman at a Chinese restaurant and started to follow the grown-ups by having a drink or two. Adults said, ‘Even if you are young, you are an adult in social life!’ Then, they gave me a drink.” (case 31)“I drank for the first time when I dropped out of high school as a sophomore and started working in a factory. At first, after the night shift, I could not sleep, so I drank a glass or two at the recommendation of my senior colleagues.” (case 32)As mentioned in several previous studies ,42,43, tmakgeolli kettle in my mouth.” (case 10)“The wrong drinking culture and tolerance for alcohol made me alcoholic. From junior high school days, when I was running errands, it was fun to hold the “A bottle of soju, which I started drinking at the age of 16, led me to addiction. I thought big and small mistakes were caused by alcohol and not by me.” (case 33)makgeolli or beer during adolescence is a natural idea. Many people drank that way.” (case 34)“Drinking In summary, curiosity, elevated mood, and stress relief were internal factors that enabled adolescent drinking, and family , friends, older friends at school, adult neighbors, Korean tradition of alcohol making (homemade), workplaces that recommended alcohol, and generous drinking culture were the external factors. This is illustrated in Compared to existing studies, the internal factors identified in this study were similar to those identified in the existing studies. However, school seniors, neighbors (adults), drinking culture, and workplaces encouraging alcohol were not pointed out in previous studies but served as a trigger for drinking in adolescence. The commonality of these factors is that older drinkers recommended or forced alcohol. From an ecological systems theory perspective, an individual adapts by interacting with surrounding environmental systems, such as family and neighbors . To adapAlthough this study discovered internal and external factors that influenced Koreans’ first drinking experience in adolescence, there are several limitations. First, because we extracted data from the alcoholic recovery notes, we could not examine phenomena other than the contents in the notes. Additionally, the contents of the collected data were written around past experiences. The research participants were unable to look at a series of changing life processes because the data were not collected during adolescence. Therefore, in future research, it is necessary to specifically explore the drinking experience of adolescence through 1:1 in depth interviews. Second, this study does not have quantitative figures. Thus, it is not shown the tendency of drinking experience among adolescents. Therefore, in future research, it is necessary to confirm the tendency of adolescent drinking through quantitative research. A follow-up study can be conducted based on these limitations.First, strengthening the regulation of adolescent drinking is necessary. This study found that adolescent drinkers were influenced by adults and older friends at school, who recommended alcohol. Currently, in Korea, only restaurant operators who sell alcohol to teenagers are punished. To improve the system, it is also necessary to consider punishment for adults who recommend and youth who drink alcohol. In case of difficulty in amending the law, it is necessary to revise school regulations to manage the consumption and recommendation of alcohol.Second, a government-led campaign is needed to overcome the generous alcohol culture. To solve this problem, a government-led campaign to stop drinking alcohol is needed, such as the smoking cessation campaign. Previously, Korea experienced a reduction in the smoking rate of citizens through active government-led anti-smoking campaigns. To change the tolerant drinking culture that negatively affects youth, various activities such as TV advertisements, mandatory education on the dangers of drinking, and counseling support through community health centers should be carried out by applying the smoking cessation campaign model. Particularly, the culture of making and drinking alcohol at home was also related to drinking opportunities during adolescence. Therefore, it is necessary to take this into account when campaigning. The culture of making alcohol at home should be protected because it is a traditional Korean culture. Even so, because homemade alcohol is also alcohol, the government needs to guide parents so that they can be aware of this and pay attention to its storage.Third, the status of early employment and youth training should be checked. Results showed that young people in early employment and industrial training were more exposed to alcohol by hanging out with adults at work. Considering these factors, a survey should be conducted on the drinking conditions of working youth. Based on this, it is necessary to develop a strategy to prevent alcohol consumption by youth who work in industries.Fourth, it is necessary to use a local crime watch. As a result of the study, those who experienced drinking alcohol in adolescence drank at local hills and parks. In Korea, there is a network of local crime watches. It is necessary to make the most of this and manage adolescents who drink outdoors at night.Finally, an integrated approach to the adolescents’ drinking problem is needed. As a result of the study, various factors, internally and externally, were influencing adolescent drinking behavior. Therefore, mental health experts need to take a comprehensive look at the drinking problem of adolescents by considering various internal and external factors at the same time.The purpose of this study was to explore the factors that affect adolescent alcohol drinking. The study found that the internal factors that influenced drinking in adolescence were curiosity, elevated mood, and stress relief, and external factors included family, friends, older friends at school, neighbors, Korean tradition of alcohol making, a workplace that recommended alcohol, and generous drinking culture. Among these, the newly identified factors were older friends at school, the neighbors, Korean tradition of alcohol making, and the workplace that recommended alcohol.We understood the findings from an ecological systems theory perspective that emphasizes the interaction between individuals and the environment. Therefore, to understand the drinking of adolescents, it is necessary to consider not only the individual’s internal motivation but also the ecological environment that affects it.


Manacus vitellinus).Video recordings are useful tools for advancing our understanding of animal movements and behavior. Over the past decades, a burgeoning area of behavioral research has put forward innovative methods to investigate animal movement using video analysis, which includes motion capture and machine learning algorithms. These tools are particularly valuable for the study of elaborate and complex motor behaviors, but can be challenging to use. We focus in particular on elaborate courtship displays, which commonly involve rapid and/or subtle motor patterns. Here, we review currently available tools and provide hands-on guidelines for implementing these techniques in the study of avian model species. First, we suggest a set of possible strategies and solutions for video acquisition based on different model systems, environmental conditions, and time or financial budget. We then outline the available options for video analysis and illustrate how different analytical tools can be chosen to draw inference about animal motor performance. Finally, a detailed case study describes how these guidelines have been implemented to study courtship behavior in golden-collared manakins ( Our understanding of animal behavior often depends on our ability to precisely quantify movement. The way animals move in space is critical for survival  and reproduction (courtship to obtain copulations), and specific changes in body position, configuration, speed, or orientation can be linked to adaptive values in different model systems. Measuring movement comes with many challenges, including environmental factors, the size and speed of the animal or body parts of interest, and the spatial scope of the target behavior. To advance our understanding of the functional significance of behavior, we need to choose the right tools.Uraeginthus cyanocephalus)  .Columba livia) to study wing and body kinematics during take-off and landing  that perform a “moonwalk” to impress females, and the blue manakin (Chiroxiphia caudata) where several males dance together . We conclude with general remarks on the future possibility of fully automated analysis of animal behavior using video recording and analysis of animal movements.In this article, we discuss key issues in the use of video recordings to study elaborate and complex motor behavior in laboratory and field conditions and provide some general guidelines , lens(es), lighting, and a data storage medium. Video recording equipment that is suitable for capturing animal movements ranges from stand-alone consumer-grade cameras to completely custom-made set-ups including dedicated lighting and multiple computers see . In thisText Box 1 Glossary of terms related to video recording systemsAperture: Size of the opening in the camera lens; determines the amount of light falling on the image sensor; influences the depth of field  and motion blur.Codec: Scheme for encoding and decoding digital video. Most codecs involve “lossy” data compression, typically tailored to human perception and discarding any information that is imperceptible to humans at normal viewing speed. Compression may influence the outcome of later video analysis.Depth of field: The portion of space that will be rendered in sharp detail in the recorded image; determined by the aperture and other lens properties.Exposure: The total amount of light falling on the image sensor during the acquisition of each frame; determined by aperture and shutter speed.Focus: In zoom lenses, the focal length can be changed, which affects the distance from the camera which will be rendered sharpest in detail.Frame rate: the number of images acquired by the camera per unit time; usually defined as frames per second (fps). The standard rate used in cinema films is 24 fps.Gain: Available in some recording systems, gain allows for an increase in the amplitude or brightness of the acquired image; also increases any noise present in the image.Lens: Focuses light onto the camera’s image sensor; main property that can be altered is aperture, and focus for zoom lenses. Depending on the camera, interchangeable lenses may be used.Shutter speed: determines the duration used to acquire a single image; also known as exposure time. Longer durations require less ambient illumination, while short durations are best for capturing fast-moving objects.Spatial resolution: the physical size of the acquired image in pixels; higher resolution images require more memory for file storage.Lens properties including focal length and aperture determine the angle of view and depth of field (see Text Box 1), and objects that are located outside the depth of field will not be in focus in the recorded image. Video recording systems are therefore particularly useful when the movement of interest is spatially limited and repeatedly performed within the same space, as in animals that possess territories or perform courtship displays in leks—display grounds where males gather to compete for females . The dimParotia carolae) who construct and maintain display courts have been filmed from behind blinds located close to their courts , where courting couples are highly mobile, sometimes travelling dozens of meters between episodes of a full courtship interaction , while the animals were housed in plexiglass boxes with lighting conditions optimized to enhance image quality. Laboratory conditions also allow more control over which individuals appear in recordings, making post-processing of videos easier.At the other extreme, laboratory-based video recordings can allow complete experimental control of the volume of space in which the animal moves and therefore equipment is typically fixed in position , we chose to track the whole individual as a single object. This allowed us to use a lower spatial resolution and frame rate, which kept file sizes smaller. This aspect is particularly important in field settings.C. capitator performs a behavior called wing-fanning  at >200 Hz and the authors used 1,000 fps to record the behavior  of golden-collared manakins happen at a rate of 60 Hz, corresponding to a duration of <16 ms, and a frame rate of 2,000 fps was required to study this movement in detail . The malbehavior .Although frame rates available in standard action cameras are relatively fast  from the camera can change rapidly, making changes in a manual focus setting impossible to perform. The same is true of exposure, as the amount of available light may change over the course of a recording, either gradually or suddenly. If possible, automatic exposure should be enabled, particularly if the movements and not the visual appearance of the focal bird are important. In recording systems where automated settings for focus and exposure are not available, and particularly in recording systems where the cameras cannot be physically accessed by the experimenter, the ability to remotely change related parameters is highly advantageous (see “Case study: 3D motion capture in golden-collared manakins” section). Finally, wild animals can roam around freely and can move outside the field of view of the camera at any time, or become occluded by other elements in the environment . Direct Depending on the research question, it may be necessary to record from more than one camera or additional devices like microphones. Whenever multiple recordings are made simultaneously, it is important to either synchronize them or to measure the relative timing of the different recording devices. A hardware synchronizer directly triggers the acquisition of each frame by each camera . In our It is important to keep in mind that different hardware devices may differ in their internal clocks. Even if there is only a small, sub-millisecond difference in their timing, this will accumulate over time and the recordings will drift apart. The use of a hardware trigger signal is extremely advantageous in such cases, as the onset of each video frame is temporally marked, allowing recovery of synchronization for later time-points of interest in a long recording. Alternatively, a clapperboard can be used to mark at least two time-points  to provide an estimate of drift to compensate for it in post-processing.Sometimes the use of multiple cameras to simultaneously record video from different viewpoints may solve otherwise very difficult challenges. For example, in our laboratory recordings of ring doves , then 3D recordings are probably not necessary.The planning of any project is subject to budget constraints. For video recording equipment, options range from bespoke systems available from companies specialized in recordings of animals, to the commercial equipment preferred by amateur sports video producers, through to lower budget, open-source solutions see . In geneThe equipment used can have an impact on the time plan of any project. Therefore, planning should consider the training needed for researchers to be able to acquire videos of high enough quality for later analysis. Time-intensive activities during recording include the set-up of mobile recording systems  or downloading and copying video material at the end of the day . In general, it is always good practice to look through recordings as often as possible during the entire recording phase of the project to check their quality and content.The increasing temporal and spatial resolution of recording systems has the consequence that extremely large amounts of data are generated when recording animal movements. We do not cover issues related to video file types and codecs, or sensible file-naming conventions here, but note that these are important. In this section, we cover some of the options available for processing and analyzing video data.Before starting data analysis, recordings should be checked to confirm the intended content and quality. Some systems, such as automatically triggered camera traps, produce substantial amounts of unwanted video material due to false triggers . In our example case of fixed camera traps positioned at bowers of spotted bowerbirds  of interest in the frames of interest. Manual annotations of large amounts of video data can be very time consuming, and automated annotation approaches are becoming more established . Once apWhile automatic methods can increase efficiency and repeatability, manual annotations may be more efficient than automatic tracking under particular circumstances. For example, in colonial species gathering in their hundreds or thousands, it might simply not be possible to efficiently train a model to automatically track individual(s) of interest as the trained model may fail to consistently track the visual features of interest on target individuals filmed on a background of many similar individuals. Additionally, automatic annotation of a full sequence of movement  might not be necessary depending on your research question. In both cases, manual annotation can be a more accurate and efficient solution. The time required to manually annotate training images, train and validate the algorithm, and then process the resulting coordinates  might in some cases be longer than manually annotating only the points of interest at the times of interest. For example, when recording King penguin courtship in the field  using the change over time in y coordinates of the eye relative to the foot.Second, detecting and tracking movements of specific points on an animal’s body is referred to as keypoint estimation. When an animal is stationary, keypoint coordinates can be used to calculate the movement of single body parts relative to the whole body. This is useful in courtship displays in which coordinated movements of single body parts  using the same approach, transforming it into millimetres using a scale present in the image. In courtship studies, coordinates defining the receivers’ movements may also be of interest, particularly cues signaling receptivity. Female bowerbirds solicit copulations by slowly crouching on the display arena, and a simple estimate of this movement can be obtained by measuring the vertical distance between head and feet key points and analyzing its change over time. Slow or rapid changes may be used as a correlate of receptivity or distress during courtship, respectively, both of which may predict changes in behavior in the courting male , and a commercial software for automated tracking and 3D reconstruction . Cameras  were connected to a computer and a hardware synchronizer .We recorded courtship displays from three cameras at 60 fps and a resolution of 1,920×1,200 pixels. This was the optimum recording quality for capturing the movement of interest with good spatial and temporal resolution and reasonable file size, considering that we were interested in the motion of the jumping bird and not in viewing any specific body parts . Cameras were synchronized using a hardware synchronizer (see section “Simultaneous multi-device recordings”). Before each recording session, we positioned the cameras on gorilla pods or tripods at different heights around the bird’s arena at a distance of 1–3 m, and set the aperture and focus manually on the lens of each camera. We removed any small branches and leaves that occluded the cameras’ views of the court.Camera calibrations refer to the acquisition of precise knowledge about the optics  of the cameras and their positions relative to each other . Therefoz-values of the points of the multi-arm structure to “lift” space and prevent negative z-values. Otherwise, it seemed that the bird was jumping underground which would have caused difficulties for further analysis.So far, several methods and algorithms have been developed for camera calibrations  for automated tracking and subsequent 3D reconstruction of a bird’s movement. In this study, we used the entire collection of manual annotations of male courtship videos from a previous field season  to train the machine learning algorithm to detect the bird without using markers. Annotations were made of the entire bird using a bounding box . After acquiring automated tracking results for each 2D recording, we used calibrations to combine tracked videos to reconstruct the 3D space (see “From image space to world coordinates” section). The final output of automated tracking was text files containing mp speed .Here we have discussed different applications of video recordings and motion tracking in the context of quantifying movements to better understand avian courtship. New technologies allow us to address and answer research questions from novel perspectives. For example, particular movements in a courtship display can provide information about different aspects of male quality (vigor versus skill) and allow us to study whether they undergo sexual selection and play a role in female choice , 2021.An alternative to using video to capture movements is the use of bio-loggers such as gradiometers/accelerometers. These devices can provide a higher sampling rate than video, but only record data from the single viewpoint of the tracking device. As it might be impossible to place such devices on the precise body part of interest, or indeed on multiple body parts, we believe that video recordings are essential for describing the movements involved in courtship. This also applies to many other animal behaviors. We have shown that video recordings require considerable planning, as many different aspects have to be considered. Although time-consuming, collecting high-quality video material should be considered a good investment. Video analysis techniques are rapidly developing and may allow us to answer open research questions by applying new technologies to previously recorded videos.We emphasized in the section “Post-Processing video material you have collected” that manual annotations of movements may be sufficient, depending on the precise research question. Training of automated tracking algorithms can be time-intensive, and includes the careful selection of representative training data. Overall, machine learning has great potential for the analysis of large sets of complex data needed to answer contemporary questions in animal behavior . This isAll procedures in the manakin case study were authorized by the Smithsonian Tropical Research Institute and the Autoridad Nacional del Ambiente of the Republic of Panama .This work was supported by several funds including start-up funds to L.F. by the University of Vienna and the University of Veterinary Medicine, Vienna as well as grants from the Austrian Science Fund (FWF) [W1262-B29], and Vienna Science and Technology Fund (WWTF) [CS18-021]. J.J. received a travel grant (KUWI MA) from the University of Veterinary Medicine, Vienna. This material is based upon work supported by the National Science Foundation under grant number 1457541.icab095_Supplementary_DataClick here for additional data file.