Substance use as well as use of video games is frequent among young people. The purpose of this research was to study the links between the use of video games and the consumption of various substances such as alcohol, tobacco or cannabis at adolescence. In order to do so, 1423 students from middle and high schools filled an auto-questionnaire that included questions on age, gender, year of study, use of video games and consumptions of alcohol , tobacco , and cannabis . We found that 92.1% of teens use video games and 17.7% have a problematic use of video games (PUVG). Furthermore, results show that substance consumption seems frequent with 19.8 and 8.3% of participants having hazardous alcohol and cannabis consumptions respectively and 5.2% having a moderate to high tobacco dependence. Video gamers consumed significantly more alcohol and gamers with PUVG started their substance consumption  earlier. PUVG was found to be negatively correlated to age at first substance consumption, but positively correlated to the time spent playing video games. However, it was not correlated to risks of substance dependence . Finally, our results are consistent with the literature, in regard to frequency of substance use and use of video games in adolescence. These data will allow for a better consideration of prevention strategies and future care in this particular field. Experimenting with psychoactive substances, such as alcohol, tobacco or cannabis, is common during adolescence . PlayingAn HBSC survey  carried out on a young population aged between 11 and 16 years old, shows that alcohol, tobacco and cannabis intake are quite frequent and increases with age. Thus, among the students of the sixth grade, 59.3, 12.7, and 1.5% had already consumed alcohol, tobacco and cannabis, respectively. Moreover, 6.8% of sixth graders and 34% of ninth graders have reported getting drunk .According to the ESCAPAD survey (2011) (or in French: “Enquête sur la Santé et les Consommations lors de l’Appel de Préparation A la Défense”), approximately 75% of 17-year-old youngsters declare having consumed alcohol, 42% declare having consumed tobacco  and 26.8Use of video games is common amongst children and adolescents . In factThe notion of “addiction to video games” is not yet an established disorder. Nevertheless, “Internet Gaming Disorder” has been introduced in the section III of the DSM-5  than the ones who did not .When it comes to alcohol consumption, it seems to be the most associated to the time spent playing video games. In fact, When it comes to age at first substance consumption, initiation to alcohol use before the age of 13 was found to be significantly correlated to frequent use of television, computers and video games .When it comes to substance abuse and dependence, the prevalence of alcohol abuse was found to increase with time spent playing video games in a Norwegian population varying from 16 to 74 years old . In addiInterestingly, n = 190) who played video games daily did not consume more alcohol or tobacco than those who played once or twice per month.However, some studies failed to find a relation between the time spent playing video games and consumption of certain substances. Thus, Our sample consisted of 1423 French students, aged between 11 and 17 years, recruited from middle and high schools  in the region of “Ile de France.” The students were informed about the objectives of our study and participated voluntarily by completing an auto-questionnaire during school hours. The parents were also informed about their rights to refuse their children’s participation in this study. This study followed the recommendations given by the committee of ethics of the Psychological Science and Learning Science department, University of Paris Ouest Nanterre La Défense, UFR SPE (Department of Psychology and Education). The education authority of Versailles, the participating schools and the higher education establishments also accepted the questionnaire.The auto-questionnaire consisted of two parts: the first included general questions about gender, age and level of study. The second was divided into four sections:The PUVG questionnaire was used. In order to assess PUVG, this questionnaire was established in reference to the criteria for substance dependence in the DSM-IV-TR , which allows a quick detection of current tobacco dependence  on 1728 students. It was also validated in the general population by The CAST (Cannabis Abuse Screening Test) was used. This test was validated in France by a survey called t-test, Chi-square, Pearson’s correlation) in order to investigate the possible links between the variables. Finally, multivariate analyses  were carried out in order to highlight the variables, which had a significant statistical weight on PUVG while taking them all into account. Thus, we were able to highlight the percentage of variance explained and trace profiles of “video gamers” with PUVG.SPSS 19 was used for all statistical analyses. Descriptive analyses  were carried out in order to describe the sample population. Subsequently, we carried out bivariate analyses (Student’s N = 1289) were considered video gamers against 7.9% (N = 111) non-video gamers. Among the players who replied to the PUVG questionnaire (N = 1192), 17.7% (N = 211) presented a PUVG (with three or more points). Only 1.1% of them exhibited all the criteria (maximum score of 7 points). Time spent playing video games on a school day was significantly lower than on a day without school . Moreover, video gamers with PUVG spend more time on video games than video gamers without PUVG [on days with school ] and without school .A total of 92.1% , fixed consoles (75.2%), and cell phones (66%). As for the types of games, they are, racing games (54.8%), platform games (48.9%) and sports games (48.3%).Around half of our population (46.7%) declared consuming alcohol. The mean age at first consumption was 12.4 years (SD = 2.7). We noticed that 89.3% of first consumptions took place after the age of 8. In other words, one out of 10 adolescents had tasted alcohol for the first time before the age of 8. Moreover, 19% have an at-risk consumption of alcohol.Approximately 16.7% of our population declared smoking cigarettes. The average starting age reported was 12.8 years (SD = 1.9). We found that 90.3% of smokers started smoking at the age of 10 or above. Moreover, 5.2% have a high tobacco dependency.A total of 21.1% of students declared having smoked cannabis at least once in their lifetime and 8.3% have had hazardous cannabis consumption, while 8.6% declared currently smoking.p = 0.04). No other significant differences were found between the two groups for the variables presented in Table Video gamers have a significantly higher consumption of alcohol than non-video gamers  as well as on a day without school . Smokers were found to spend more time playing video games.Factorial ANOVA was performed in order to study the time spent playing video games on a day with as well as without school for those who consume alcohol, cannabis and tobacco versus those who do not. The ANOVA was significant. Bonferroni’s F = 3.3, p = 0.02]. In particular, video gamers have a higher score on AUDIT-C  and on CAST  than non-video gamers. However, no difference was found when analyzing the score on HSI (p = 0.538).We also conducted a MANOVA with the dependent variables AUDIT-C, HSI, and CAST comparing the two groups of video gamers and non-video gamers. The MANOVA shows overall substantial differences between the two groups.  for these variables.We also conducted a MANOVA with the dependent variables age at first consumption of alcohol, tobacco and cannabis comparing the two groups of video gamers and non-video gamers. However, no significant differences were found between these two groups [Table N = 100), we notice a significant correlation between the score on PUVG and HSI . Similarly, if we consider those who consume cannabis (N = 150) we observe significant and positive correlation between their score on PUVG and CAST .If we take into account only those who smoke (R2 = 0.3776) of the variability of PUVG score. The significant descriptive variable in this model are time spent playing video games on a day with school , age at first consumption of cannabis  and age at first consumption of tobacco  (Table We tested a linear regression model in an attempt to explain the score of PUVG (dependent variable) by the scores of AUDIT-C, HSI, CAST, age at first substance(s) consumption(s) and time spent playing video games . It should be noted that this analysis included a smaller sample than the initial one, consisting of 108 subjects who consume or have consumed the three substances. This regression model explained 37.76% (R2 = 0.367). Time spent playing video games on a school day (b* = 0.292) and age at first consumption of cannabis  as well as, the score on HSI (b* = 0.148), time spent playing video games on a day without school (b* = 0.191), score on CAST (b* = 0.153) and age at first consumption of tobacco  were the variables, which were selected by this method.We also carried out a step-by-step ascending regression (R2 = 0.32). Time spent playing video games on a school day (b* = 0.446), age at first consumption of cannabis (b* = –0.18) and score of HSI  were the variables, which were selected by this method.Similarly, we also carried out a step-by-step descendant regression .N = 1423), we found 92.1% of video gamers (N = 1289) and 17.7% of video gamers with PUVG (N = 211). Substance use  in this population was frequent, which goes in accordance with the epidemiological data in the literature  show that there exist at least two significant differences between video gamers and non-video gamers with respect to their score on substance dependence . However, no significant differences were found with respect to age at first consumption for the two groups.There were no significant differences in time spent playing video games between consumers of alcohol and cannabis and non-consumers. This time was significantly longer for tobacco smokers than non-smokers. These results are consistent with those of It must be noted that longer time spent playing video games during a day without school is associated with an earlier age of first substance consumption . These results are in accordance with those of Previous studies have focused on finding a link or a co-occurrence between PUVG and substance use, as mentioned earlier. Our results are inconsistent with the literature  since PUProblematic use of video games seems to be associated with an earlier initiation of substances since there exists a significant negative correlation between PUVG score and age at first substance consumption . Hence, an earlier starting age is linked to an increased risk of PUVG. To our knowledge, these data have not been explored by other studies.Furthermore, only 36.76% of the variability of PUVG score was explained by our regression model that include scores of AUDIT-C, HSI, CAST, age at first substance consumption and time spent playing video games (on a day with/without school) as independent variables. Age at first consumption of tobacco and of cannabis, time spent playing video games on a day with school explain the variance significantly. The two variables that stood out (despite the method of regression used) were, time spent playing video games on a school day and an earlier age of first consumption of cannabis.It is to be noted that our study has some limitations; starting from the questionnaire measuring PUVG which is based on the DSM-IV-TR. Moreover, our sample was a convenience sample: recruitments were only carried out in schools that voluntarily accepted to participate in the study. Groups of video gamers versus non-video gamers and those with or without PUVG are not matched, which does not allow us to exclude or control some confounding variables, such as academic results. In fact, according to some authors , there eIn addition, a qualitative study based on hetero assessment would allow us to refine our results, which as of now are only based on auto-evaluations.Problematic use of video games and consumption of psychoactive substances  are frequent at adolescence. Adolescents who play video games consume significantly more alcohol than non-video gamers. This was not the case for tobacco or cannabis consumption.Despite the limitations of the instrument we used to assess PUVG, our results provide important information on the associations, poorly investigated, between playing video games and use of alcohol, tobacco, and cannabis in an adolescent population. Thus, age of first substance consumption  does not differ significantly between video gamers and non-video gamers but is negatively correlated to PUVG score and time spent playing video games on a day without school. The risk of developing a substance dependence  was not found to be correlated to PUVG score but was positively correlated to time spent playing video games. On the other hand, the age at first consumption of tobacco and of cannabis and the time spent playing video games on a day of school were significant predictors of PUVG.An earlier age of substance consumption is associated with PUVG. Thus, it seemed important to point out that, although PUVG is potentially transient, substance consumption initiated earlier predisposes to the development of future dependences. Therefore, there is a need to highlight prevention and information on the appropriate use of new technologies by adolescents and young adults, and particularly the use of video games. However, our results only highlight the possible links between the variables and do not indicate the direction of the relationship between the variables. Longitudinal studies with more robust tools are necessary in order to throw light upon the possible underlying mechanisms.Our team of research has received funding from the gambling industry operators (FDJ and PMU) and IREB (Institut de Recherches Scientifiques sur les Boissons—“Institute for Scientific Research on Drinks”).


We report a unique surgical treatment for external coxa saltans refractory to previous open and endoscopic management in a patient with Ehlers–Danlos syndrome. After failure of two endoscopic iliotibial band (ITB) lengthenings and one open gluteus maximus (GMax) lengthening, a novel procedure was conducted, which involved release of the GMax insertion and tenodesis of the anterior and posterior portions of the ITB to prevent pathologic translation over the trochanter.2) visited our institution with an 8-month history of debilitating ITB snapping that was unresponsive to prior attempts at non-operative treatment. On examination, she was globally hypermobile and had painful and reproducible snapping of the right ITB over the greater trochanter.An 18-year-old female with Ehlers–Danlos syndrome . The posterior division of the ITB and GMax was then secured using these anchors. The anterior fibers of the IT band were sutured to the anterior vastus lateralis and greater trochanter, as seen in At a minimum follow-up of 6 months, the patient did not experience symptomatic recurrence and had improved with respect to pain control and physical function.Symptomatic external coxa saltans is usually amenable to non-operative treatment. However, in rare cases, surgical intervention is warranted , 2. ExteNumerous techniques, both open and endoscopic, have been reported for the treatment of the external snapping hip. Refractory snapping that has not responded to prior surgical treatment presents a challenge to surgeons. Revision options are sparse, and there is a relative paucity of information regarding treatment for these patients who are typically young, active and demand a more functional lifestyle .Our novel procedure limits pathologic translation of the IT band and GMax over the greater trochanter by statically anchoring the offending structures. For refractory cases of IT band or GMax snapping that has failed prior endoscopic and open interventions, GMax release with tenodesis of the IT band is a reasonable revision option that has demonstrated success in short-term outcomes.Brian Giordano is a paid consultant for Arthrex.


Active video games may contribute to reducing time spent in sedentary activities, increasing physical activity and preventing excessive weight gain in adolescents. Active video gaming can, however, only be beneficial for weight management when it replaces sedentary activities and not other physical activity, and when it is not associated with a higher energy intake. The current study therefore examines the association between active video gaming and other energy-balance-related behaviours (EBRBs).P < 0.001 (Mann Whitney test)). No differences between these groups were found in other EBRBs. Among those who played active video games on assessed days, active video game time was positively yet weakly associated with TV/DVD time and snack consumption. Active video game time was not significantly associated with other activities and sugar-sweetened beverages intake.Adolescents (12–16 years) with access to an active video game and who reported to spend at least one hour per week in active video gaming were invited to participate in the study. They were asked to complete electronic 24-hour recall diaries on five randomly assigned weekdays and two randomly assigned weekend-days in a one-month period, reporting on time spent playing active and non-active video games and on other EBRBs. Findings indicated that adolescents who reported playing active video games on assessed days also reported spending more time playing non-active video games  compared to adolescents who did not report playing active video games on assessed days  contains supplementary material, which is available to authorized users. Replacing non-active video games (video games that are played sedentary) with active video games  may contribute to reducing time spent in sedentary activities. Thus, physical activity may be increased and excessive weight gain in adolescents may be prevented ,2. PlayiIt is, however, unclear how active video gaming is associated with other energy-balance related behaviours (EBRBs). This is important, as active video gaming may only be beneficial for energy balance when it replaces sedentary activities such as non-active video gaming or watching TV. When adolescents play active video games instead of other physically active activities such as outdoor play or sports, active video gaming will not contribute to increasing total energy expenditure ,6. AnothA Dutch youth panel consisting of 2800 12-16-year-old adolescents with access to an active video game were invited to participate in the study and were screened for eligibility. This resulted in 596 adolescents who were willing to participate and met the criterion of spending at least one hour per week engaged in active video gaming. An active video game was defined as a video game that requires movement of the body, more than movement of the fingers and hands alone [Adolescents were requested to complete electronic 24-hour recall diaries on five randomly assigned weekdays and two randomly assigned weekend days during a one-month period (April 2011), excluding holidays. On the assigned day, the adolescents were notified at 4 pm by a text message and an email which included web links to the diary. A reminder was sent the next morning at 8 am if the diary was not completed by that time. The diary could be completed until 9 am on the same day. Participants received a voucher worth 7.50 euro when all seven diaries were completed (in addition to the standard reward points system of the agency for each time they participate in a research).In total 458 participants completed their diary on at least three weekdays and one weekend day, which we considered a minimum for reliable estimates, and these were included in the analyses  were assessed in the inclusion criteria screening questionnaire.We developed an electronic 24-hour recall diary to assess engagement in and time spent on a range of EBRBs  was regarded as realistic, but when the different activities added up to more than double the available minutes in a specific time slot it was regarded as missing. Next, we categorized the activities into the following nine categories: 1) active video gaming, 2) non-active video gaming, 3) watching TV/DVD, 4) PC use other than video gaming, 5) non-screen sedentary activities, 6) sports and active play, 7) other physical activities , 8) consumption of snacks and 9) consumption of sugar-sweetened drinks . All statistical analyses were carried out using SPSS for windows, version 21.We used non-parametric tests because the data was non-normally distributed. First, time use differences between adolescents who reported active video game play (active video gamers) at assessed days and adolescents who reported no active video game play at assessed days were tested with the Mann–Whitney test. Next, Spearman correlation coefficients were computed to evaluate associations between active video gaming time on the one hand and on the other hand non-active video gaming time, TV time, non-video gaming PC time, non-screen sedentary time, sports, other physical activities and consumption of snacks and sugar-sweetened drinks. The correlation coefficients were interpreted based on Cohen’s  guidelinThe mean age of the participants was 13.7 years (SD = 1.4), 58% were male, 98% were of Dutch ethnicity, 9% attended primary school, 43% pre-vocational secondary education and 48% higher or –pre-university secondary education.P < 0.001). Time spent in other activities and consumption of snacks and sugar-sweetened beverages did not differ between the two groups (Table P = 0.047) and consumption of snacks . No associations were found between active video gaming and the other EBRBs (Table In comparison with adolescents who did not play active games on the assessed days, the active video gamers spent significantly more time on non-active video gaming (Mann–Whitney U = 19025.5; Adolescents who reported playing active video games, also reported spending more time playing non-active video games than those who reported not to have played active video games. Other EBRBs did not differ between the two groups. These results suggest that an interest in active and non-active video gaming is associated, which may indicate that replacing non-active video game time for active video game time is possible. This is in line with an earlier study that showed that most adolescents who play active video games also play non-active video games . HoweverWhile active video gamers reported spending significantly more time on non-active video gaming than other adolescents, there was no significant association between the time spent on active video gaming and that spent on non-active video gaming time among the active video gamers. This may be a preliminary indication that the promotion of active video gaming would not result in a reduction of time spent on non-active video gaming. Support for this idea can be found in an earlier study that concluded that making active video games available in their home did not result in a decrease in self-reported non-active video game time . Our resA limitation of the current study is the self-report of behaviour, which is prone to socially desirable answers. The questions were based on validated questionnaires for assessing energy-balance related behaviours -17, but In summary, the results of our study suggest that it is unlikely that time spent playing active video games substitutes other physical or sedentary activities. However, spending more time playing active video games seems to be associated with a small, but significant increase in TV/DVD time and intake of snacks. Caution is therefore warranted in using active video games in health promotion, as such an intervention may have unexpected side effects.


The mobility of active and passive internal rotation was significantly higher in handball players in both shoulders. The handball group presented lower internal rotation range of motion for the dominant shoulder as compared to the non-dominant shoul-der (p=0.001).: Young handball practitioners, des-pite skeletally immature, showed a higher MRT than the control group. The handball group showed loss of internal rotation  on the dominant shoulder as compared to the non--dominant shoulder. Level of Evidence II, Prospective Study. Handball is a pitch and contact sport that determines high demands of the shoulder joint, using positions and movements that lead to high risk for ligament, tendon and capsular injuries of this joint.The humeral torsion or humeral head retroversion (UHR) is an anatomical feature that exists only in monkeys and hu-mans; it is defined, in anatomy, as the spiral movement of this bone, stabilizing at the end of growth with the closure of the humerus proximal epiphyseal line.In athletes practicing throwing sports such as handball, abduc-tion and external rotation take place, generating adaptations both of soft tissue and bone structure.There are several instruments to evaluate GIRD. Among them, stand out bio-photogrammetry This study aimed to evaluate the prevalence of humeral head retroversion and characteristics of rotational shoulder mobility in young handball practitioners.This is a cross-sectional study conducted between September and October 2013. The sample consisted of 27 young wom-en, aged 15.07 ± 1.17 years. The sample was divided into handball practitioners group (n = 14) and non-practitioners (control) group (n = 13). Young female, aged between 15 and 17 years, regular hand-ball practitioners and non-practitioners of other pitch sports, with stable vital signs and normal physical condition were included in the study. Girls with a history of shoulder joint in-jury in the last six months, practitioners of other pitch sports, who have had surgery in the neck or upper limbs, general ligamentous laxity and neurological or systemic disease were excluded from the study.Universidade Luterana do Brasil , Torres, RS, Brazil, under protocol number 319 570/2013. Along with the coach and their parents, the study subjects were informed about the research and were asked to sign a Free and Informed Consent Form (FICF) drafted in accordance with the Guidelines and Regu-latory Norms of research involving human subjects from theThe study was approved by the Research Ethics Committee of the Resolução do Conselho Nacional da Saúde nº196/96.The assessment protocol was explained right away and after the parents/legal guardians signed the FICF, volunteers were submitted to evaluation.Initially, the young participants of both groups were evalu-ated for their anthropometric aspects. They were weighed in a previously calibrated Mallory(r) (Brazil) digital scale using light clothing and no shoes on. Three measurements were performed, and their median was recorded. Height was mea-sured using a Megaforth(r) (Brazil) self-locking 8m measuring tape. Three measurements were made and their median was recorded. Finally, we calculated the body mass index (BMI) of all study subjects.The measurement of external and internal rotation ROM of both shoulders (dominant and non-dominant) was performed either passively as actively through goniometry and bio-photogrammetry. Goniometry was performed with the subject lying supine on a stretcher with his shoulder in 90° abduction and elbow flexed at 90°. The examiner stabilized the shoulder at the same time that the active and passive external and internal rotation movements ROM were measured on both dominant and non-dominant sides. The center of the goniometer was positioned in the olec-ranon of the ulna, the fixed arm of the goniometer remained fixed and aligned on the vertical axis to the ground, while the movable arm accompanied the movement aligned to the mid-dle line of the forearm.(r) (Brazil) digital camera was used. The subject remained lying supine on the table with her shoulder abducted 90° and elbow flexed at 90°. White, spherical 13mm non-reflective surface markers were used, placed on the olecranon and the ulnar styloid process. Images of active and passive ROM of both shoulders were acquired with the shoulder in neutral rotation, maximum external rotation and maximum internal rotation. The camera-subject distance was 2.10 m, with a photographic tri-pod at one meter from the ground. The examiner performed the stabilization of the glenohumeral joint during movement. After-wards, the images were transferred to a computer and analyzed by Corel Draw 9.0(r) software. The maximum active and passive ROM of internal and external rotation of each shoulder was cal-culated, as well as the active total rotational movement (TRM).For evaluating rotational mobility of the shoulder through bio-photogrammetry, a 7.2 megapixels no-zoom Sony DSC W120p <0.05. We use the SPSS , version 17.0, as statistical package.A descriptive analysis of the study variables was carried out with data expressed in frequency, mean and standard deviation. For evaluation of angular measurements between athletes and controls we used the unpaired Student t-test. For evaluation of the dominant and non-dominant shoulder within each group, we used the Pearson correlation test. The significance level for the statistical test was The sample was divided into two distinct groups: handball group, formed by 14 young female practitioners of competitive handball, aged 15.57 ± 1.16 years, height 163.93 ± 0.06 cm, BMI 23.56 ± 3.31, and the control group, made up of 13 young women from a high school in the city of Torres, RS, Brazil, not practitioners of handball or other pitch sports, aged 14.54 ± 0.96 years, 159.9 ± 0.05 cm height, BMI 23.50 ± 4.28. Both groups were homogeneous regarding age, height, BMI, skin color and dominant upper limb. The internal rotation mobility of both active and passive shoulders measured by goniometry was significantly higher (p <0.05) in the handball group both for the dominant as non-dominant shoulder. The external rotation was significantly higher in the handball group only in the passive form in the non-dominant shoulder. When we evaluated the active and passive mobility of external and internal rotation by bio-photogrammetry, the young hand-ball practitioners also showed a significant increase in active internal rotation of the dominant and non-dominant shoulders. The passive ROM of this group was significantly higher only in the non-dominant shoulder. Passive ROM was significantly higher in the handball group in both dominant and non-domi-nant shoulders (p<0.05). The handball group presented both in goniometry and bio-photogrammetry a significantly lower active and passive in-ternal rotation ROM for the dominant shoulder. In contrast, we observed a significantly higher ROM in passive external rota-tion of the dominant shoulder by goniometry (p <0.05). Bio-photogrammetry showed similar results as goniometry. There was a significantly lower internal rotation ROM of the dominant shoulder (p <0.05). There was no significant difference in TRM between dominant and non-dominant shoulders. In the control group we found that external rotation was sig-nificantly higher in the dominant shoulder in both active andpassive forms. The internal rotation ROM was higher in the non-dominant shoulder than the dominant shoulder, but only in the passive movement (p <0.05). There was also no sig-nificant difference in TRM comparing the dominant and non-dominant shoulders. Due to the scarcity of studies evaluating UHR and GIRD in young skeletally immature handball athletes, we sought to in-crease knowledge about the effects generated by the practice of pitching on young women and their possible implications in adulthood.In this study, we sought to evaluate UHR, represented by GIRD in young handball practitioners and non-practitioners. This con-dition is characterized by the increase in lateral rotation range of motion and reduced medial rotational.± 1.17 years. Osbahr et al.,Levine et al., In another study, Murachovsky et al.When we evaluated the results of our study, we observed that in the handball group there was no difference in passive and ac-tive external rotation between the dominant and non-dominant shoulders. In contrast, we found a significant loss of internal rotation. The average passive external rotation in the handball group in our study was 129° measured by the goniometry and 126° by bio-photogrammetry. A study by Nodehi-Moghadam et al.Recently, Bigliani et al.In our study, despite the young handball practitioners showed a decreased internal rotation in the dominant shoulder, the TRM of the handball group was significantly higher than the con-trol group's. Wilk et al.The TRM in our study showed no significant difference be-tween dominant and non-dominant shoulder in both groups.However, it was significantly higher in the handball group as compared to the control group. Wilk et al.Young women in early stages of handball training sports sho-wed a significant loss of internal rotation in the dominant shoul-der as compared to the contralateral shoulder, characterizing GIRD. However, the TRM was significantly higher in the handball group as compared to the control group.The results suggest that stretching of the posterior capsule may be one of the aspects to be addressed in the prevention of further injuries in young handball practitioners. We suggest that further studies on this topic are carried out to increase the scientific knowledge on shoulder rotational mobility cha-racteristics of young handball practitioners and its possible implications in adulthood.


Chronic malnutrition, including stunting, is an important example of a global challenge that spans multiple sectors, specifically health, agriculture, and the environment. The objective of this paper is to review current knowledge on the causes and consequences of chronic malnutrition and their relationship with multiple sectors. Understanding the causes includes approaching chronic malnutrition from the basic, underlying, and immediate levels. The causes reach from macro-level environmental influences to specific micronutrient intake. In order to effectively address stunting, it is important to understand the timing of stunting and the ability of individuals to catch up in terms of linear growth, cognitive ability, and immune function. The consequences of chronic malnutrition are transgenerational and they have an impact at the individual, community, and national level in the short- and long-term. There are still many gaps in knowledge regarding both the causes and consequences of chronic malnutrition, particularly when it comes to the interaction with agriculture and the environment, and understanding these gaps is important to addressing the burden of chronic malnutrition through evidence-based interventions. The primary objective of this paper is to assemble current knowledge regarding chronic malnutrition in relation to multiple sectors. Sustainability must be at the forefront for each sector to address the challenges of chronic malnutrition. The paper will focus mainly on stunting as the most common manifestation of chronic malnutrition. To understand chronic malnutrition, we must define the syndrome, causes, and short- and long-term consequences. We will then discuss how these consequences can be addressed through evidence-based nutrition-specific and -sensitive interventions and governance. Furthermore, the contribution to the manifestation of chronic malnutrition by multiple sectors will be discussed.As more global attention is directed toward combating stunting, there needs to be a clear understanding of what the nutrition community and the wider development community knows about stunting, how stunting is related to chronic malnutrition, and why stunting is used as an indicator for chronic malnutrition. This understanding is key for guiding future programing and policy. There are still many unknowns related to the causes and effects of chronic malnutrition that impact the way in which interventions are designed and implemented. Some of these unknowns are found within the biomedical realm. For example, we do not yet know how specific micronutrients contribute to growth failure and the ability and timing of children to catch up. Other unknowns include, which interventions are most effective during specific times in the lifecycle, particularly interventions from the agriculture and environment sectors.Chronic malnutrition is defined as a form of growth failure that causes both physical and cognitive delays in growth and development. Stunting, also known as linear growth failure, is defined as the inability to attain potential height for a particular age, and it is the most common measurement used to identify chronic malnutrition. However, stunted growth is only one manifestation of chronic malnutrition. Compared to children who have been given optimal opportunities to grow and develop, a chronically malnourished child will be challenged to attain the same height, will likely not develop the same cognitive ability, and will have higher risk of poor health outcomes throughout life. The “window of opportunity,” or critical period of growth and development between pre-conception and 2 years of age, has been an important focus for the nutrition community . The winTypes of malnutrition fall into two general categories, acute and chronic. Acute malnutrition, most often demonstrated by wasting, is frequently seen in temporary or cyclical settings like emergencies, seasonal depressions, and highly infectious-disease environments. Globally, more children under 5 years of age are stunted than wasted; 165 million compared to 52 million in 2011, respectively . There aThe majority of stunted children live in low- and middle-income countries, with the highest proportion in African countries, where 35.6% of all children under 5 years are stunted, and the greatest absolute number in Asian countries, where 95.8 million children under 5 years are stunted . CurrentThe causes of chronic undernutrition are multidimensional, which create many challenges in understanding the condition and finding solutions through interventions and policies. There is no single root cause of chronic malnutrition. The future strategies to address chronic malnutrition need the collaboration of multiple sectors and a variety of stakeholders in governments, non-government organizations, the donor community, and the private sector. This paper aims to capture and explain the multiple dimensions of chronic undernutrition and the importance of a multi-sectoral, sustainable response to improving nutrition that incorporates perspectives from agriculture, health, environment, water and sanitation, infrastructure, gender, and education.in utero, a child may be born smaller and with an impaired immune system. Similarly, a child may respond to undernutrition in infancy and early childhood with a slower growth rate  . A studyOther underlying causes of malnutrition are inadequate care practices, which include lack of exclusive breastfeeding and poor IYCF practices. Breast milk is important component of an infant’s intake and is key to help build a strong immune system . Exclusiz-score by 0.08 standard deviations.   . Furtherhe mean) . The timhe mean) .The consequences of stunting can be both short- and long-term. In the short-term, stunting can result in increased risk of mortality. Mortality is complex to measure, since a child may not die from being stunted as a primary cause. Rather, stunting can be an underlying factor contributing to a child’s vulnerability and susceptibility to morbidities. In 2010, child and maternal undernutrition  were responsible for 1.4 million deaths or 6.7% of all DALYs (disability adjusted life years) according to the Global Burden of Disease Study . Within Morbidity or burden of disease can be caused by both the suppression of the immune system and subsequent long-term chronic health problems. Vitamin A, zinc, and iron are all related to compromised immune function, increased occurrence of infections, and increased risk of stunting , 58. StuLong-term effects of stunting impact the health, education, and productivity of children as they become adults. One long-term consequence of chronic undernutrition is a decrease in cognitive ability. There has been much research on this association both with educational attainment and wages gained in adulthood. In a study of Peruvian children, chronic malnutrition, as measured by stunting in infancy, leads to poor cognitive development later in childhood . AdditioChronic malnutrition in early childhood not only affects educational attainment but also cognitive ability as an adult and therefore economic earnings in the long-term . In ruraAnother long-term effect of stunting on morbidity is an increase in the risk of non-communicable diseases such as cardiovascular disease and diabetes related to being overweight or obese. In biological terms, stunting leads to impaired fat oxidation and glucose intolerance . Severalin utero to be small-for-gestational age, which manifests as a low-birth-weight infant at birth. This is most easily seen in the nutritional relationship between mother and child throughout both pregnancy and infancy. If a mother enters her pregnancy with poor nutrition status, she is more likely to give birth to a low-birth-weight or stunted infant  in some studies, but there was no significant reductions overall in child growth indicators such as stunting, wasting, and underweight. Some studies individually found reductions in stunting, including a dairy goat project in Ethiopia and a legume intercropping project in Malawi . The secAddressing the nutrition-disease interaction includes interventions such as promotion of handwashing, improved sanitation and water quality, promotion of exclusive breast feeding for the first 6 months, promotion of appropriate complementary feeding including hygienic food handling, increased dietary diversity, and prevention of other diseases such as respiratory tract infections and malaria. As there is clear evidence that the causes of malnutrition have a direct correlation with the WASH environment, it is critical to address. In one study, it was found that hand washing before the preparation of children’s food decreased the incidence of diarrhea. It has been shown that diarrheal incidence increases around 6 months of age when complementary foods are introduced, which is also during the critical period of growth. If WASH interventions can reduce diarrhea, it could have an impact on a child’s cognitive ability, either through an increased ability to attend school or through a decrease in the risk of stunting. Nutrition-specific interventions, if scaled and utilized can have a significant impact on the reduction of stunting, micronutrient deficiencies, and wasting. These interventions target pregnant and lactating women and children under 2 years of age , 104. NuNational policy and advocacy are needed to create enabling environments for nutrition action. An analysis of advocacy as intervention shows how cultural and political context play a role in the effectiveness of advocacy . AdvocacThis paper reviews the academic literature on current definitions, causes, consequences, and interventions of chronic malnutrition. Additional research is still needed, especially related to the times at which children become stunted and the timing of linear growth catch up. Evidence is also needed on how to increase multi-sectoral nutrition-sensitive interventions . This isAddressing the burden of stunting is inextricably linked to wider progress toward the Millennium Development Goal targets ending in 2015, the new Sustainable Development Goals post-2015, and overall development of nations. Significant gains will hinge on concurrent steps to reduce poverty, improve access to education, empower women and girls, and facilitate access to basic infrastructure including safe water and sanitation, energy, transport, and communication. Working on multiple fronts simultaneously has the potential to leverage synergies and catalyze gains that extend beyond those achieved through sector specific programs working in isolation .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The Flinders Telehealth in the Home trial , conducted in South Australia, was an action research initiative to test and evaluate the inclusion of telehealth services and broadband access technologies for palliative care patients living in the community and home-based rehabilitation services for the elderly at home. Telehealth services at home were supported by video conferencing between a therapist, nurse or doctor, and a patient using the iPad tablet.The aims of this study are to identify which technical factors influence the quality of video conferencing in the home setting and to assess the impact of these factors on the clinical perceptions and acceptance of video conferencing for health care delivery into the home. Finally, we aim to identify any relationships between technical factors and clinical acceptance of this technology.An action research process developed several quantitative and qualitative procedures during the FTH trial to investigate technology performance and users perceptions of the technology including measurements of signal power, data transmission throughput, objective assessment of user perceptions of videoconference quality, and questionnaires administered to clinical users.The effectiveness of telehealth was judged by clinicians as equivalent to or better than a home visit on 192  occasions, and clinicians rated the experience of conducting a telehealth session compared with a home visit as equivalent or better in 90.3% (489/540) of the sessions. It was found that the quality of video conferencing when using a third generation mobile data service (3G) in comparison to broadband fiber-based services was concerning as 23.5% (220/936) of the calls failed during the telehealth sessions. The experimental field tests indicated that video conferencing audio and video quality was worse when using mobile data services compared with fiber to the home services. As well, statistically significant associations were found between audio/video quality and patient comfort with the technology as well as the clinician ratings for effectiveness of telehealth.These results showed that the quality of video conferencing when using 3G-based mobile data services instead of broadband fiber-based services was less due to failed calls, audio/ video jitter, and video pixilation during the telehealth sessions. Nevertheless, clinicians felt able to deliver effective services to patients at home using 3G-based mobile data services. The Flinders Telehealth in the Home trial  was conducted in South Australia during 2013 to 2014. The trial introduced telehealth services in community-based palliative care and home-based rehabilitation services for the elderly .For all groups, clinical teams emphasized the need for solutions appropriate for patients ≥65 years of age. The applications needed to be simple to use and interoperable with existing information and communications technology (ICT) infrastructure used by the health services. The equipment chosen was low-cost, consumer-grade, and as far as possible, based on non-proprietary standards.ServiceCommunity-based palliative care: Patients and their carers received video-conferencing and remote monitoring services from a palliative care nurse using a tablet device , a self-assessment application to record their health status, and electronic devices and scales to monitor their physical activity and weight.Home-based rehabilitation services for the elderly: Patients were remotely monitored by a therapist who made video calls as required . They alClinical care was delivered from the Repatriation General Hospital, Adelaide, South Australia to participants using Internet Protocol-based video conferencing. Connectivity between the hospital and participants was achieved through the following mechanisms (1) the Australian National Broadband Network (NBN), a fixed line fiber to the premise network (FTTP) and (2) an Internet Service Provider (ISP) such as third and fourth generation (3G/4G) mobile data services .Participants in their own homes were lent an Apple iPad tablet with WiFi connectivity to a NBN "ready" router with inbuilt wireless IEEE 802.11n (WiFi) and a NBN connection with a bitrate of 25 Mbps/5 Mbps  or an ApThe video conferencing application used by the clinicians and FTH trial participants was based on a proprietary system Vidyo  hosted iPrior work has identified the importance of technology factors on the success of home telehealth . The resAn action research process developed several procedures during the FTH trial to investigate technology performance and users perceptions of the technology .Ethical approval was obtained through the Southern Adelaide Clinical Human Research Ethics Committee (HREC), application number HREC/13/SAC/88(168.13 and 203.13).ProceduresSimple tests of signal power, data download, and upload rates for Telstra mobile data 3G services (Telstra 3G) for differing received signal powers were undertaken at selected locations. Measurements of the signal powers for 4G services were not undertaken because in areas of poor coverage the equipment falls back to use 3G services.Development of an experimental method to objectively measure the quality of audio, video, and failed calls in the field using Telstra 3G and FTTP services provided by the NBN.Assessment of the reliability of video conferencing calls over the NBN and Telstra 3G using call log data from the Vidyo system to determine the average duration of calls, possible failed calls, and reconnection attempts.A questionnaire for clinical video conferencing users of the NBN and Telstra 3G services to assess their experiences between the 3rd of March, 2013 and the 25th of July, 2014.Due to the variable nature of radio propagation in the bands used by mobile data services it was difficult to validate Telstra 3G geographical coverage maps. In order to sample the real life performance of Telstra 3G services, a total of 249 measurements of the signal power levels (dBm) reported by the FieldTester  application on the iPad tablet device  were madTo investigate the influence of using NBN compared with Telstra 3G networks on video conferencing an experimental method was developed to measure the quality of audio and video conferencing between a tablet device used by patients and a clinician’s computer. Each test involved a patient tablet that was placed in front of a media source which streamed the content to the clinician’s computer using a video conferencing client . As the Clinical users felt that the key quality markers for a video conference were the number of times a call failed and had to be re-established, absent or delayed audio or video (jitter), and significant pixilation of the video. Using database software specifically developed to record the observations of the number and durations of negative events, each individual event (jitter and/or pixilation) observed was assigned with a start and end time. Failed calls were also counted. A failed call was a call that was unexpectedly terminated and included calls that were unable to complete a connection. While the results can be considered subjective, the same ICT staff member conducted all tests to minimize variances in the evaluation process.Round trip Ping delay and signal power (dBm), as reported by the FieldTester application, were recorded using a second tablet at 10-second intervals; the begin and end timestamps of the other events were recorded with a one-second granularity throughout a call session time of 2700 seconds (approximately 45 minutes). A call session time of 45 minutes represented the average duration of a rehabilitation session. Average durations for palliative care were shorter (8 minutes).Devices were configured to use Telstra 3G mobile data services only, because all 4G services will fall back to 3G services when the 4G signal power fades. This represented a more realistic telehealth conference as the targeted patient geographical locations were often in areas with poor 3G or 4G coverage. The different test combinations of broadband technology (Telstra 3G or NBN) and the different tablet devices that were tested are shown in An automated log of the calls made during the FTH trial using the Vidyo video conferencing system provided data for reliability analysis using the statistical software package SPSS. Call log records (N=4763) covered the period from October 20, 2013 to July 25, 2014.The call log contained data regarding the call duration, patient or clinician identifier and device identifier, the call start and end times, whether the call was via a conference room or direct, information on whether the call completed successfully or failed, and the call direction (incoming or outgoing). Data in the call log was cleansed of call records unconnected with clinical service , and calls records were grouped to represent telehealth sessions when clinicians provided services to patients. A telehealth session comprised one or more calls and lasted between 5 to 45 minutes. If the first call to a patient failed for any reason, subsequent calls may have been made to re-establish the telehealth session. A total of 1021  valid successful or unsuccessful telehealth sessions were identified.After each clinical consultation clinicians were asked to complete a computer-based questionnaire about the telehealth consultation that had just taken place. A total of 687 responses were received for consultations that used Telstra 3G and NBN technologies .QuestionsClinicians’ perception of video and audio quality (1 very poor - 5 very good)Whether the patient appeared to be comfortable with the technology Why was the patient uncomfortable with the video conference? Rate and comment on the effectiveness of using telehealth with patients compared with home visit (1 much worse - 5 much better)Rate and comment on experience of using telehealth with patients compared to home visit (1 much worse - 5 much better)To facilitate statistical analysis in SPSS, responses to questions about video and audio quality responses merged from 5 categories to 3. The “very good” responses were recoded as “good”. Similarly, the “very poor” responses were recoded to “poor”. Questions requesting further information as free text comments were graded for relevance to results of respondent's assessments using NVIVO 10 qualitative analysis software.Clinical teams did encounter poor coverage in areas previously identified by analysis of Telstra 3G coverage maps. It was also observed that the location of the home and its construction could result in poor interior reception and that weather conditions were an additional factor. At one location signal power measurements (N=54) made during wet weather showed lower mean signal levels and greater variability than at the same location (N=32) during dry weather at −96.1 dBm (SD 8.3) and −86.7 dBm (SD 0.6), respectively. The analysis of all 249 measurements by signal power levels  for data transmission rates, and latency in milliseconds is provided in Most noticeable were the high variability of the upload (SD 0.61) and download (SD 0.56) rates, which in some cases, when signal powers were low, could reduce the minimum bitrates to values which could limit video and audio quality. At low power levels the average network latency rose to 96ms which may reduce the audio quality.The majority of the testing was undertaken when signal power was moderate but many instances of weak signal power were observed. Visual examination of 37 hours of experimental recordings of Telstra 3G signal power and events such as network packet "Ping" delay and/or audio and video jitter showed no time correlation between signal power and other events .A comparison of the mean number of adverse events during each video conferencing session for each test combination shows the best performance was achieved by an iPad tablet via WiFi and NBN . While tAcross all test combinations, with the exception of those involving the NBN, the duration of the video, audio pixilation, and video jitter events varied from about 5 to 45 seconds with mean values between 15 and 20 seconds. Failed call events were of particular interest because these caused significant issues to telehealth sessions. Only one failed call was observed on the NBN. For the principal configuration deployed in the FTH trial (an iPad connected via Telstra 3G), 4 calls failed during 21 sessions lasting 45 minutes each. Differences between the performance of the iPad, Samsung Tab, and Android FonePad devices were observed for similar connections.Of all the telehealth sessions identified in the call log, 936  were deemed successful. A successful session comprised one or more completed calls in the Vidyo call log. During the successful telehealth sessions, 220  required more than one completed video call to be made by clinicians. There were 85  failed telehealth sessions due to more than one call terminating for any reason.P<.001, Pearson chi-square coefficient 325.7). This was to be expected since both video and audio quality is related to the data transmission quality. In the clinician survey the quality of the audio and video for all types of connections was rated by clinicians as good for the majority of telehealth sessions. No statistically significant association existed between the NBN or Telstra 3G connection types and audio or video quality. Examples of clinician comments on audio, video, and reliability issues for the sessions that experienced technical difficulties are shown in A statistically significant positive association existed between clinical perceptions of video and audio quality . When the patient was comfortable with the technology, audio quality was judged as good . When the patient was ambivalent, the audio quality was good in 67.6% (46/68) of the responses. When the patient was uncomfortable with the technology, the audio quality was poor in half  of the responses. An analysis of responses for different Internet types was not possible due to small sample sizes.A statistically significant association was found between audio quality and patient comfort with the technology . When the patient was comfortable with the technology, the video quality was rated as good in 404  of the responses. Some patients were uncomfortable with the technology when initially learning how to use it , for example "couldn't turn machine on, then volume had been switched off". Some required ongoing supervision  possibly due to cognitive problems: "Continues to require phone call to open Vidyo prior to call".A statistically significant positive association existed between video quality and patient comfort with the technology . The clinicians rated the audio quality as good on 444  occasions. When clinicians rated the effectiveness of telehealth as equivalent to or better than a home visit, audio quality was reported as good in 313  occasions. A statistically significant association also existed between video quality and the effectiveness of conducting a telehealth session compared with a home visit . When the telehealth effectiveness was rated as equivalent or better, video quality was reported as good in 368  occasions.Clinicians rated the effectiveness of conducting a session using telehealth compared with a home visit as equivalent or better 88.5% (478/540) of the time. A statistically significant association existed between audio quality and the effectiveness of conducting a session compared to a home visit using telehealth  of the time. Clinicians were also asked to comment on the how easy it was to provide a telehealth session compared to a home visit. Responses showed that on 71.6% (192/268) of the occasions, clinicians rated telehealth sessions as easier than a home visit focusing on time, travel, and efficiency savings (22 comments) as being key advantages. For example, one stated "Better as more efficient, achieved equivalent outcomes with no restrictions", and another said "No travel involved, often when you visit in person you may need to wait while the patient is finishing something else, but the patients' give priority to the videoconference". Clinical issues were cited by clinicians rating the telehealth session as less easy than a home visit. For instance, one said "abandoned session", and another:More difficult this time. Previously ok when patient was non weight bearing and not allowed any ankle active movement. Now as weight bearing status has changed it was more difficult to perform my assessment and treatment.The main findings of this study are that the effectiveness and experience of home telehealth was judged by clinicians as equivalent to or better than a home visit and that the quality of video conferencing using 3G-based mobile data services in comparison to broadband FTTP services is less, due to failed calls during successful telehealth sessions, audio, video jitter, and video pixilation. However, clinicians were still able to deliver effective services to patients at home using this less than perfect technology.Experimental field tests demonstrated significantly better performance of video conferencing over the NBN FTTP network, which provided an almost error-free performance for audio and video and no failed calls, whereas a greater proportion of adverse audio and video events were observed when using Telstra 3G mobile data connections. Recent work  has alsoMeasurements of data transmission rates over a Telstra 3G mobile data connection showed that 3G signal strength was a poor indicator of download or upload bitrates, and transmission rates can drop below levels needed to maintain good video and audio quality when the signal strength was weak or moderate. The extreme variability of transmission rates that can drop to less than half the average rate was a little surprising, and can only be the result of mobile data base stations and the associated backhaul network managing data rates to accommodate multiple users in real-time within an allocated base station capacity and other factors such as interference from other radio frequency sources or variable radio propagation due to weather related atmospheric layers. These findings support the reservations expressed by Holma that:One common belief in the industry and among consumers is that a “faster network” provides a better user experience, meaning that a consumer’s experience with a smartphone will be inherently superior in an LTE network than an HSPA+/DC-HSDPA network. The reality can be somewhat different. 12It was anticipated that there could be an obvious correlation between intervals during which the 3G signal power was low and audio or video events. Further it was thought that there could be a correlation between intervals during which the "Ping" round trip delay time was high and the number/frequency of audio or video jitter events. In reality, even though large numbers of audio and video events occurred, there was no obvious time correlation observed between signal power and adverse audio, video or pixilation events, or the network delay time for 64 byte "Ping" packets.Possible explanations for this behavior are that in a mobile data wireless environment the radio base station allocates resources continuously on a sub-second time scale. Data is transmitted in 2 ms or 10 ms blocks, and depending on signal power, interference or the presence of other users, modulation schemes and coding schemes may change from block to block . These sThe relatively high ratio of failed calls to successful calls  made per telehealth session using Telstra 3G services is concerning. An average call failure rate of 23.5% during a telehealth session is high. By comparison, Telstra claims that the probability of a call failure will be less than 3% for mobile phone customers. We have no explanation for this application behavior. In theory, signaling messages between video conferencing clients require little network capacity, so calls should not fail even when video and audio quality is poor. In practice, calls do fail and fail to connect even when network capacity appears high. Despite the high failure rate of calls compared with the performance of calls on the mobile telephony network, clinical users appear to be willing to persist and try to make new calls to establish a telehealth session or re-establish a session if a call failed. On the whole, clinicians expressed satisfaction with the effectiveness of telehealth services in this health care setting even when using less than perfect telecommunications.Many limitations to this study arose from the live, in-service nature of the research. Measurements of signal power depended on the FieldTester application for the iPad. This application has no publically traceable calibration of field strengths (volts/m) to signal power readings (dBm). Packet loss and packet jitter in networks can also significantly impact audio and video quality, but we were unable to find an application for tablet devices that would measure these parameters. Measurements of download and upload bitrates using the Ookla application were dependent on a pre-determined methodology over which we had no control. Finally it should be noted that sample sizes from the clinician questionnaire were insufficient to enable comparisons between the ways different clinical services perceived video conferencing technology.Clinicians felt that the effectiveness and experience of home telehealth was equivalent to or better than a home visit even though the survey data indicated that audio and video quality during telehealth sessions was less than perfect. Clinicians persisted with using mobile data services even when calls failed and video or audio quality was degraded. We used a repeatable experimental method to measure video conferencing performance on mobile devices in the field and showed video conferencing services using 3G technology frequently suffer from failed calls, audio and video jitter, and video pixilation. Analysis of call logs also confirmed that failed calls were a frequent occurrence. As well, measurements of the data transmission capacity showed a high degree of variability, which may degrade video and audio quality.The performance of tablet hardware and operating systems (Android and Apple IOS) differed, reinforcing the need to carefully select and test telehealth systems prior to deployment. While there was no significant association between the type of Internet connection used by the patient and audio or video quality as rated by clinicians, statistical analysis of clinical perceptions shows that the effectiveness of telehealth sessions and client comfort were closely linked to audio and video quality.Field measurements for the video calls using the NBN demonstrated an almost error-free performance for audio and video. Given that 85.4% (587/ 683) of the telehealth sessions took place over mobile data services, it is reasonable to infer that the majority of audio and video quality issues experienced by clinicians could have been avoided if NBN connections had been available to participants in the project.


Restorative proctocolectomy is a current gold standard procedure for patients who require a colectomy for ulcerative colitis. The incidence of ileal pouch neoplasia is low. The aims of this study were to assess the prevalence of neoplasia in ileal pouch and investigate the risk factors for ileal pouch neoplasia.A total of 276 patients who underwent restorative proctocolectomy for ulcerative colitis between 1984 and 2009 were analyzed. Results of histological examinations of both original specimen and biopsies from the J-pouch taken during routine pouch endoscopy were evaluated. Patients’ records were analyzed for ulcerative colitis duration, the time from pouch creation to pouch neoplasia, presence of pouchitis, as well as the concurrent primary sclerosing cholangitis.n = 8) or adenocarcinoma (n = 1) of the J-pouch were positive for dysplasia in the original specimen. Duration of ulcerative colitis before surgery and duration time following restorative proctocolectomy were found as risk factors for J-pouch neoplasia with a significant difference . Patients with pouch neoplasia developed significantly more severe pouchitis (p = 0.00001).Analyzing the original specimen of large bowel, fifty-six lesions of low-grade dysplasia, twenty-five high-grade dysplasia, and five adenocarcinoma were revealed. All patients with dysplasia (Neoplasia of the J-pouch is rare. Patients with neoplasia in the original specimen are more susceptible to develop neoplasia in the J-pouch. Precise follow-up in patients with neoplasia lesions in the original specimen should be recommended. Moreover, in patients with risk factors, the exact surveillance pouch endoscopy should be recommended. Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is a current gold standard procedure for ulcerative colitis (UC) patients who required surgical treatment.Ulcerative colitis is a well-known risk factor for colorectal cancer (CRC). The presence of dysplasia as well as adenocarcinoma of the large bowel mucosa constitute the indications for surgical management . It was In general, the prevalence of dysplasia and adenocarcinoma in the ileal pouch is low. The cumulative incidence of ileal pouch neoplasia (both dysplasia and cancer) at 10 and 20 years in UC patients following RPC was 1.3 and 4.2 %, respectively [Although many potential risk factors have been investigated so far, only some have been identified as a significant risk factor for ileal pouch neoplasia. Pouchitis, prior colorectal cancer, time of UC duration before RPC, concurrent primary sclerosing cholangitis (PSC), and type of IPAA (presence of mucosectomy) were the most common indicated as reported risk factors –7.The first case report of pouch dysplasia was reported in 1991 . Since tIn the recent study, we proved that pouchitis may increase the risk of J-pouch dysplasia following RPC for UC patients . The maiThe study was approved by the institutional bioethics committee at Poznan University of Medical Sciences.Retrospectively, we analyzed a group of 298 patients who underwent RPC for UC in our institution between 1985 and 2009. Exclusion criteria were patients diagnosed with Crohn’s disease based on the final histopathological examination. Finally, 276 patients were included into the study. Data was collected based on the available medical records. Patients’ records were analyzed for sex, age, duration of UC before RPC, duration from pouch creation to pouch dysplasia, technique of IPAA anastomosis, presence of pouchitis, and pouchitis disease activity index (PDAI) score as well as the concurrent PSC.RPC was performed in a standard manner. In our institution, only the J type of pouch configuration was performed. The first 27 procedures were performed with hand-sewn IPAA. In remaining patients, stapled IPAA was carried out. Depending on variety of factors , two- or three-stage RPC was performed Table .Table 1CRetrospectively, histopathological examination of the large bowel in all patients was evaluated. Routinely, the original specimen was prepared in the standard manner  and sent for histopathological examination. Analysis was carried out regarding no neoplasia, CRC, or dysplasia (low-grade dysplasia (LGD) or high-grade dysplasia (HGD)) of mucosal large bowel.Clinical examination and endoscopy of the pouch with biopsy performed yearly were routinely practiced as an institutional standard follow-up in UC patients following RPC. Pouch endoscopy was performed usually in the Pouch Outpatient Clinic with the usage of a rectoscope of various sizes (8 or 15 mm in diameter) depending on the IPAA diameter established during per rectum examination. It was performed by one of four surgeons who were well-experienced in endoscopy. Routinely, multiple biopsies were taken from (1) the body of the pouch and (2) IPAA. Additional biopsy was taken from each suspected mucosa within the ileal pouch. Routinely, we did not take biopsy of the anal transition zone (ATZ) unless there were any macroscopic changes. Histopathological examination was performed by a gastrointestinal pathologist and approved by a second pathologist.We analyzed and performed statistical examinations of 846 biopsies performed from 2004 to 2009. Most of the examinations were performed in our center, and we included data regarding 24 endoscopic examinations from other outside centers.Pouchitis was diagnosed based on PDAI when at least 7 points was achieved. Chronic pouchitis was diagnosed in patients in whom at least three episodes of pouchitis were diagnosed within 12 consecutive months and at least in the course of one episode pouchitis was confirmed during an endoscopic examination with biopsy .n = 9) and patients without diagnosed foci of neoplasia in the pouch (267 patients). Chi-square test (Pearson’s test) was performed to confirm the correlations between certain characteristics such as the presence of pouch neoplasia and dysplasia or neoplasia in the large intestine before RPC, duration of UC before RPC, and intensity of PDAI. Statistically significant results were those with a p value <0.05. All the statistical analyses were performed using Statistica 10 .The analyzed results were presented as an average ± standard deviation. As part of the statistical examination, patients were divided into two groups: patients with pouch neoplasia (The study group comprised of 127 women (46.1 %) and 149 men (53.9 %). The mean age at the time of surgery was 43.2 years (SD 11.9). The mean time of UC duration before RPC was 11.5 years , whereas the mean time of follow-up was 9.8 years .n = 5) patients, adenocarcinoma of the large bowel was revealed. In the remaining samples (n = 190) of the original specimen of the large bowel, there was neither dysplasia nor adenocarcinoma.Based on the histopathological examinations of the original specimen of the large bowel, 56 patients with low-grade dysplasia and 25 patients with high-grade dysplasia were diagnosed. In five (n = 5), LGD was revealed; in three patients (n = 3), HGD was diagnosed; whereas in one patient (n = 1), adenocarcinoma was confirmed. The analyzed group of patients with J-pouch neoplasia consisted of five males (n = 5) and four females (n = 4). All reported patients with J-pouch neoplasia were positive for neoplasia in the original specimen of the large bowel . Patients diagnosed with either pouch adenocarcinoma (n = 1) or HGD (n = 3) were qualified for pouch excision. In two patients with LGD, pouch excision was performed as well: one patient with concomitant severe pouchitis refractory to conservative treatment and in the second one because of concomitant pouch dysfunction. Remaining patients were qualified for endoscopic excision without any further repercussion. Mostly in the group of patients treated with an endoscopic approach, polypoid lesions were diagnosed. All patients diagnosed with neoplasia and treated either surgically or endoscopically required close follow-up (every 3–6 months).Based on the available medical records, we analyzed the results of biopsies taken during routine J-pouch endoscopy. Patients’ characteristics with dysplasia and adenocarcinoma of the ileal pouch are displayed in Table ient n = , adenocap = 0.01). The mean duration of UC before RPC in the group of ileal pouch neoplasia was 23 (SD 4.6), 20 (SD 1), and 21 years, respectively, for LGD, HGD, and adenocarcinoma.Duration of ulcerative colitis before RPC was revealed as a significant risk factor for pouch neoplasia . There was no significant difference in the mean age between groups with LGD, HGD, and adenocarcinoma: 41.8 (SD 4.7), 40.3 (SD 1.5), and 38 years, respectively.p = 0.00001). In the group of pouch neoplasia, the mean PDAI score was 8.8 (SD 1.6), 9.7 (SD 0.6), and 11 for patients with ileal pouch LGD, HGD, and adenocarcinoma, respectively.Patients with pouch neoplasia developed significantly more severe pouchitis  than patients without neoplastic changes of ileal pouch mucosa (p = 0.0003). The more severe pouch neoplasia  was revealed, the longer the time following RPC was assessed. Neoplasia was revealed 13.6 (SD 4.6), 17.3 (SD 3.1), and 20 years after RPC for patients with ileal pouch LGD, HGD, and adenocarcinoma, respectively.Duration from pouch creation to pouch neoplasia was significantly longer in patients with ileal pouch neoplasia than in patients without pouch neoplasia , stapled IPAA was performed. However, in three patients with hand-sewn IPAA (and mucosectomy), pouch neoplasia developed.Introduction of the stapled technique for IPAA allowed for lower perioperative complication rates as well as functional disorders of the neo-rectum resulting in anal canal sensations or sphincter disturbances . HoweverIt was proven that secondary bile acids may contribute to the increased risk of neoplasia in patients with UC and concomitant PSC . StahlbePouchitis is the most common complication of the pouch in UC patients following RPC . The preBoth dysplasia and colorectal cancer in the original specimen of the large bowel at the time of RPC were risk factors for developing neoplasia of the ileal pouch , 19. AltBranco et al. found that the duration of UC before RPC in the group of patients with pouch cancer was longer than those without neoplasia (20.3 vs 11.2 years) . These rPouch endoscopy is a current gold standard investigation for follow-up in patients following RPC. However, the success rate in detecting dysplastic lesions of the pouch is still low. In the analyzed data of 42 patients with diagnosed adenocarcinoma of the pouch, in 23 of them, any neoplastic lesions were found before the final diagnosis of adenocarcinoma was revealed . AccordiThe natural history of pouch neoplasia is still a topic that has not been fully examined yet. Despite the fact that potential risk factors for the development of pouch neoplasia have been defined, the precise protocol regarding the care of patients after RPC is still a topic of discussion. It has been established that there is a low incidence of pouch neoplasia. Although, some authors questioned the necessity of performing pouch endoscopy as surveillance, in our opinion, such surveillance should be recommended , 24. RegBased on the analyzed results in this study, it is still a question whether pouch endoscopy surveillance in the group of patients with prior colorectal neoplasia should be performed more often. The significant correlation between prior colorectal neoplasia and pouch neoplasia allows to think that the correlation is strong and associated with a high risk of pouch neoplasia.We would like to emphasize the necessity for prophylaxis for chronic pouchitis which is a trigger for pouch neoplasia. All patients in the group with pouch neoplasia except one had a high correlation between the presence of pouchitis and the presence of pouch neoplasia, strongly suggesting initiation of a long-term prophylaxis and treatment for chronic pouchitis .It should be noted that the final pathological diagnosis regarding hyperplastic and reactive adaptive changes as well as pouchitis and low-grade dysplasia may be easily confused. Thus, it is recommended to assess the histopathological specimen by at least two pathologists .There are some limitations of the study. Routinely, we did not perform multifocal biopsies of the ATZ unless any suspected macroscopic lesions were revealed. As a standard in our Institution, we routinely took samples from the body of the pouch and IPAA. However, based on the study presented by Thompson-Fawcett et al., multifocal biopsy was not found as necessary in patients following RPC and UC within a duration of 10 years . Moreove


Three-dimensional (3D) video is expected to be a “killer app” for OFDMA-based broadband wireless systems. The main limitation of 3D video streaming over a wireless system is the shortage of radio resources due to the large size of the 3D traffic. This paper presents a novel resource allocation strategy to address this problem. In the paper, the video-plus-depth 3D traffic type is considered. The proposed resource allocation strategy focuses on the relationship between 2D video and the depth map, handling them with different priorities. It is formulated as an optimization problem and is solved using a suboptimal heuristic algorithm. Numerical results show that the proposed scheme provides a better quality of service compared to conventional schemes. Recent advances in video technology have made three-dimensional audio/video (3D A/V) services technically feasible. 3D A/V has emerged to provide more immersive experiences compared to conventional two-dimensional (2D) video. It allows viewers to feel a compelling sense of physically real spaces. Therefore, it is expected to be a “killer app” for smart-phones and corresponding broadband wireless systems.3D A/V is generated by multiview images, which is obtained in two ways: through multiview cameras , 2 and wInstead of using raw data of multiviewed images, the DIBR technique makes use of two types of images: 2D texture images and synchronized depth maps. This is known as the video-plus-depth concept, which was introduced by the advanced three-dimensional television system technologies (ATTEST) project . These tAs mentioned above, the 3D A/V service is expected to become widely popular on smart-phones and corresponding broadband wireless systems based on the orthogonal frequency division multiple access (OFDMA). OFDMA technology is known to be suitable for next-generation broadband wireless systems because high-speed data transmission is possible under limited radio resources. However, the size problem is still severe in OFDMA-based wireless systems because the limited radio resources represent a fundamental problem of current wireless systems. Though the video-plus-depth concept based on the DIBR technique can reduce the amount of data compared to the multiview camera method, the amount of 3D A/V traffic is still large enough such that it can hardly be transmitted over a wireless system in real-time. Therefore, the efficient resource allocation of radio resources is important to guarantee the QoS of a 3D A/V service.In OFDMA-based wireless systems, resource allocation is performed by means of a scheduling procedure. There have been many scheduling algorithms for wireless systems. The maximum carrier-to-interference ratio (Max C/I) , round-rIn this paper, we propose a resource allocation scheme for wireless transmissions of 3D A/V traffic. We focus on a QoS guarantee for 3D A/V services in the proposed scheme. To do this, we adopt a concept which uses a base layer and an enhancement layer for 3D A/V traffic, as introduced by video-plus-depth concept. This concept processes 3D traffic more efficiently.The rest of this paper is organized as follows: first, we give an overview of the system environment in which the proposed scheme is adopted in This section gives an overview of the system environment in which the proposed resource allocation scheme is adopted. It begins with an introduction of the overall system architecture of 3D video over wireless systems. Also, a detailed description of video-plus-depth 3D video is discussed.The media server sends RTP packets to the wireless system through an IP network. In this paper, we consider wireless systems based on the orthogonal frequency division multiple access (OFDMA), such as the long-term evolution (LTE), LTE-advanced (LTE-A), IEEE 802.16e, IEEE 802.16 m, and other technologies. In The PDN GW or serving GW connects the IP network and the LTE-A system. The RTP packets of the base layer and the enhancement layer data come into the LTE-A system through the general packet radio service (GPRS) tunneling protocol (GTP). GTP is an IP-based protocol which is used in the universal mobile telecommunications system (UMTS) network. GTP-U in eNB receives user data through GTP-U/UDP/IP and then sends the data to the UE through the RAN. Each instance of data is passed through the packet data convergence protocol (PDCP) and the radio link control (RLC), after which it is segmented and encapsulated as one or more medium access control (MAC) frames and inserted into MAC buffer. The base layer traffic and the enhancement layer traffic are inserted into logically separated MAC buffers. In the eNB MAC layer, radio resources are allocated by scheduling. After resource allocation by scheduling, eNB repeatedly reads MAC frames from the MAC buffer and sends them to the UE through the RAN.Upon receiving the MAC frames, the UE reassembles and decapsulates them as RTP packets through RLC/PDCP/IP/UDP layers. The RTP packets are combined into the base layer and the enhancement layer data. Each layer of data is decoded so as to recover the depth map and the 2D video, respectively. Finally, they are converted into a 3D video stream and displayed by the display screen of the UE.In this paper, we focus on the video-plus-depth representation of multiview 3D video which renders a 3D video using a 2D video stream and its associated depth map. This type is widely used because it provides a flexible representation of 3D and because it is compatible with existing coding and transmission technologies .In this format, the depth map includes 256 leveled grey images. It also contains depth information about the pixel positions of the associated 2D video. It can be acquired by a depth camera directly or can be extracted by a multiview image. The size of the depth map is related to the number of viewpoints of the 3D video. Because the resource requirements of 3D video applications based on the video-plus-depth scheme are high compared to those of 2D video applications, efficient compression techniques are required for 3D video. The layered coding approach can be effective with regard to this requirement. In the layered coding approach shown in This section gives a detailed description of the proposed resource allocation strategy adaptive to 3D video over wireless systems. First, we describe the key idea of the proposed strategy to guarantee the QoS, formulating it as an optimization problem. Next, we present a suboptimal heuristic approach to solve this problem.There have been several definitions and measures pertaining to the QoS of a 3D A/V service –8. AmongThe key idea of the proposed resource allocation strategy is that the base layer traffic is given priority when assigning resources to guarantee the QoS. In this paper, we focus on 3D video traffic based on the video-plus-depth method, which consists of a 2D video stream and its associated depth map. As noted in This idea is adopted in the scheduling procedure which works in the MAC layer of the eNB. As described in i is delivered to eNB at an average rate of packet/slot time. The packets are stored in a MAC buffer, Bi. For the 3D A/V traffic, two buffers are assigned to the enhancement layer traffic and the base layer traffic, respectively. In this paper, we assume that the buffers are large enough to not to overflow. We stipulate that the amount of data in buffer Bi at the beginning of the kth slot is xi,k. From the result of scheduling, ui,k is transmitted during kth slot. ui,k depends on the allocated data rate at buffer Bi. Then, the buffer is updated asai,k is the input traffic size in Bi during the kth slot. Let Di be the average queuing delay for Bi. Di is related to the average buffer length via Little's theorem  is the average packet arrival rate. Because 0 ≤ ui,k ≤ xi,k, the smallest average delay of the kth slot is achieved when ui,k = xi,k and the average queuing delay becomes Di = 1.We assume that traffic whose destination is UE  theorem  and is dGi,n be the channel gain, Ni,n the total noise power spectral density, and pi,n the allocated power for user i to subcarrier n. In this formulation, we consider an OFDMA based wireless system. We assume that M-QAM modulation is applied with a BER requirement. The signal-to-noise ratio (SNR) SNRi,n   is given byi on subcarrier n is normalized byi can then be described asRi while transmitting on subcarrier n is si. wi,n is the subcarrier allocation index; it has a value of 1 when subcarrier n is allocated to user i. Otherwise, it has a value of 0.Let BER)/1.5 . In addiI is the total number of UEs and Dib is the average queuing delay of the buffer which contains the base layer traffic for the UE i. Dth is the threshold delay and Smax is the total number of RE's within a slot. w = I × N, p = I × N, and PT are the total available transmission power for eNB. Note that OP is neither convex nor concave with respect to . Although wi,n is defined to obtain a value of either 0 or 1, it is permitted to be a real number between 0 and 1 to make the problem tractable.Because our goal is throughput maximization while guaranteeing the QoS, the scheduling problem can be written as shown below:Equation  represenEquation  indicatew, p), subcarrier n should be allocated to user i*. This is expressed as follows:i* with subcarrier n is given asfi* is the water-filling level of user i* [To maximize OPL=1Smax is 12 and the number of subcarriers is 6. The modulation method and coding rate are changed according to the SNR. The modulation and coding scheme (MCS) has nine levels, as shown in Because we consider an OFDMA based wireless system, we also set several OFDMA parameters. The system bandwidth is assumed to be 10 MHz and the slot time is set to 0.5 ms. We adopt the channel structure of the 3GPP Ericsson model , 20. To UEs are uniformly distributed in a cell and each UE is served only one type of traffic. In the simulation, we use two traffic models: 3D A/V traffic models and web traffic models. We assume that 10% of the UEs are served WEB services and 90% of UEs are served the 3D A/V service.The traffic model of 3D A/V used in this simulation is formulated based on the streaming video traffic model which is used for IEEE 802 systems . BecauseT represents the interarrival time between the beginnings of each frame and the packet coding delay is determined by the interarrival time between packets in a frame, as shown in β of the packet size of the enhancement layer changes according to the number of 3D viewpoints. For 8-viewpoint 3D video traffic, β is 0.45 [β is 0.9 and 1.8, respectively.In  is 0.45 . For 16-WEB traffic has a form similar to the ON/OFF model. WEB traffic consists of the main object comprising the web page and several embedded objects. They are transmitted if a web page is requested. Dth is set to 250 ms and the time margin for priority adjustment Δ is also set to 250 ms.We also assume that the buffer of UE has infinite capacity. The maximum delay bound of 3D A/V frame The performances of the proposed strategy are evaluated through the packet drop rate, the service success rate, and the QoS level. Figures As shown in Figures Figures Therefore, it is considered as “Proposed (3D)” if both the base layer traffic and the enhancement layer traffic are well transmitted. However, it is considered as “Proposed (2D)” if the enhancement layer traffic cannot be delivered due to a lack of resources and if only the base layer traffic is transmitted well. It is regarded as a service failure if both the base layer traffic and the enhancement layer traffic cannot be delivered or if only the enhancement layer traffic is delivered well.When there are a small number of users, nearly all users can receive both the base layer traffic and the enhancement layer traffic successfully. As the number of users increases, the number of users who can receive only the base layer traffic increases because the proposed strategy places priority on the base layer traffic. Therefore, the service success rate of “Proposed (2D)” increases and the service success rate of “Proposed (3D)” decreases with an increase in the number of users.ψ3D be the success rate of the 3D service and ψ2D the success rate of the 2D service. The QoS level ϖ is then defined asωq is the user's satisfaction weight for the 2D service compared to that for the 3D service. ωq has a value between 0 and 1. ωq = 1 indicates that a 3D user is fully satisfied even when watching 2D video instead of 3D video. Additionally, ωq is zero when a 3D user is fully disappointed if he watches 2D video instead of 3D video. The QoS level also has a value between 0 and 1. A value of 1 indicates a state of satisfaction and a value of 0 indicates a state of dissatisfaction. In Figures The figures show that the 3D service success rate of the proposed strategy is similar to that of the existing strategy. However, if we assume that 2D video watching is also regarded as successful service, the proposed strategy outperforms the existing strategy. The meaning of these results can be clarified when we consider them as follows: let From these numerical results, it is clear that the proposed strategy can guarantee better QoS compared to the existing strategy. The advantage of the proposed strategy becomes more evident as the rate of the enhancement layer traffic increases, or when the number of viewpoints of the 3D traffic grows.In this paper, we propose a novel resource allocation strategy for 3D video over a wireless system to guarantee the QoS. The proposed strategy focuses on the relationship between 2D video and the depth map and handles them with different priorities. Performance evaluations show that our strategy is a good choice to guarantee better QoS. In terms of several performance measures such as the packet drop rate, the service success rate, and the QoS level, our strategy is shown to outperform an existing strategy. Moreover, the advantage of the proposed strategy increases as the number of viewpoints of 3D video is increased. Therefore, we expect that the proposed strategy can be very useful for more realistic 3D traffic delivery.


Childhood obesity is a worldwide issue, and effective methods encouraging children to adopt healthy diet and physical activity behaviors are needed. This viewpoint addresses the promise of serious video games, and why they may offer one method for helping children eat healthier and become more physically active. Lessons learned are provided, as well as examples gleaned from personal experiences. Childhood obesity is a worldwide public health issue ,2, and iTechnology may offer an effective method for encouraging children to adopt healthy behaviors. Technology is pervasive in today’s world and influences many aspects of our lives, including how we communicate, educate, and entertain ourselves. Video games are an example; 97% of 12-17 year olds play video games, play multiple genres, and have access to computers and other devices on which to play the games ,11. InteWhile traditional video games are primarily designed to entertain, a new genre has emerged that seeks to do more. Serious video games, often referred to as games for health when they target health behaviors , are shoThere are several components that should be considered when developing serious games for health behavior change. These include interactivity, feedback, characters, story, and sound effects ,19. For Rather than a didactic presentation of facts or figures, the player is able to interact with and “discover” knowledge and skills, and then immediately apply these to overcoming behavioral obstacles in the game.A serious video game offers a unique opportunity to receive immediate feedback, thus refining, reinforcing, and enhancing newly found knowledge and skills.The protagonists model desired behaviors, while the antagonists attempt to “foil” the player’s efforts to attain a goal, thus adding challenge and interest.The story adds intrigue and excitement, and can be designed to “wrap” the behavioral components into the game for a more seamless experience.The sound effects convey meaning and direction without words. For example, a ticking clock or fast-paced music can indicate that time is running out or that the player must act quickly.My colleagues and I have been involved in the development and evaluation of a variety of serious video games and other technology-based interventions for a number of years -33. We hThink about the behavior you’re targeting and the project goal. It may be that another method or approach would be a better fit.For example, research suggests that video games may not be the best method for enhancing moderate to vigorous physical activity ,35. We hOnce programming has been completed, it is expensive to make a change. An approach that has worked for us is to know what you want and how the pieces fit together before starting development. For example, first identify the “serious” components that need to be included based on the theoretical framework  and the targeted behavior  . Then neSerious video games can be expensive to develop . In addiWe have seen this in our own technology-based work. Negotiation and open communication with the game design team are essential. Using the approach described above has been extremely beneficial to achieving our research goals within a reasonable budget. For example, in a serious video game promoting fruit and vegetables to youth , during The importance of research with the target audience to serious video game design cannot be emphasized enough . It is iWe used this approach when developing a serious video game for elementary aged school children . We firsA myriad of data can be collected as players navigate through the game, but not all of it may be useful . Identify in advance what data you want to capture  early in the development process. Talk with the game design studio about the data you need and how you would like these data stored in the back-end database to avoid potentially expensive (or unfortunate) surprises at the end . Data security is also an important issue that should be addressed, .When we develop technology-based programs, we typically have a discussion with the game design studio well before the end of the programming phase, where we discuss options for data collection, and how the data are stored in the database. We have learned that this process helps to avoid missteps and opens up an important discussion between key players. For example, when developing the serious video game promoting fruit and vegetable consumption , we provDeveloping serious video games is a difficult, time consuming, humbling, and exhausting experience, but it is also exhilarating. When a parent tells you what a difference the game has made in his or her child’s life, or the outcome evaluation shows the child not only played all episodes of the game, but modified their behavior, such as eating more fruit and vegetables , you reaRelax, and enjoy the journey! In my opinion, it’s well worth it.