This paper centers around the notion that internal, mental representations are grounded in structural similarity, i.e., that they are so-called S-representations. We show how S-representations may be causally relevant and argue that they are distinct from mere detectors. First, using the neomechanist theory of explanation and the interventionist account of causal relevance, we provide a precise interpretation of the claim that in S-representations, structural similarity serves as a “fuel of success”, i.e., a relation that is exploitable for the representation using system. Then, we discuss crucial differences between S-representations and indicators or detectors, showing that—contrary to claims made in the literature—there is an important theoretical distinction to be drawn between the two. Antirepresentationalism has been one of the major recent trends in theorizing about the mind. Some modern antirepresentationalists employ a sort of trivializing argumentative strategy. That is, instead of (or in addition to) developing new theories of cognition that do without the notion of representation, they attempt to show that some of the most prevalent existing notions of mental representation are not suited to do the theoretical jobs that are expected of them. In particular, the idea that representations are covariance-based indicators or detectors has been subjected to this sort of trivializing attack. It has been argued that detectors functionally boil down to mere causal mediators, and thus are not representations Ramsey , or thatstatus quo, for example, to argue that detectors are representations after all. But perhaps a different reaction is more justified and fruitful. Perhaps representationalists should treat the “trivializing” strand of antirepresentationalism as an opportunity to develop, strengthen, and indeed reform the mainstream understanding of what representations are so that the resulting new notion is no longer subject to the trivializing arguments. In fact, something like this sort of reaction is starting to take shape in the literature. This is because in parallel to antirepresentationalism, another trend in theorizing about representation has recently gained momentum, wherein people move away from seeing mental representations as indicators or detectors, and towards construing them in terms of internal models . Then we show that this causal role is indeed properly attributed to the relation of similarity as such, and does not boil down to the role played by the representational vehicle alone .Our first concern is with the idea that S-representations come into play when structural similarity can be actively exploited or relied upon by a cognitive system or mechanism. In other words, similarity relations that give rise to S-representations are The second aim of the paper is to critically examine the recent skepticism about whether S-representations are in fact distinct from detectors or indicators. In particular, Morgan  has argurepresentations only come into play when a cognitive system depends, in some nontrivial sense, on the relation of similarity in its engagements with its representational targets. As Godfrey-Smith . Users of cartographic maps owe their success to the similarity that holds between the spatial structure of the representation and the spatial structure of the territory it represents . This link between similarity and success generalizes to all S-representations, including, we claim, the ones that do not require interpretation by a human being.causally relevant to success. That is, the structural correspondence can quite literally cause the representation-user to be successful at whatever she (or it) is using the representation for, and lack of structural correspondence can cause the user to fail at whatever she (or it) is using the representation for. Explanations that invoke S-representations should thus be construed as causal explanations that feature facts regarding similarity as an explanans and success or failure as an explanandum. To exploit structural similarity in this sense is to use a strategy whose success is causally dependent on structural similarity between the representational vehicleOn the view we are proposing, explanations of success that invoke the similarity between the representation and its target can be true in virtue of similarity being Our treatment invokes two concepts that are in need of clarification, especially when applied to internal, subpersonal representations: the notion of success/failure , and the notion of causal relevance. We will now concentrate on each of these notions in turn. Let us start with success and failure.human agents can succeed or fail at whatever they use S-representations for seems straightforward enough and we will not dwell on it here. But how to understand success/failure in the case of internal, subpersonal representations of the sort that are of interest to us here? We propose to look at the problem through the lens of the prominent neomechanistic theory of explanation, as applied to cognitive-scientific explanation . Components and operations derive their functional characterization from the function of the larger mechanism they are embedded in. That is, the function of a component is determined by an operation such that it is through the performance of this particular operation that the component in question contributes to a phenomenon for which the larger mechanism is responsible  structurally similar to the representational target; and analogously, when the mechanism succeeds at realizing or enabling C, this is at least in part due to the fact that this component is (sufficiently) structurally similar to the target. So structural similarity is causally relevant to success/failure because the ability of any S-representation-involving mechanism to perform its function depends on the degree of structural similarity between the representational vehicle and the target. Success and failure are treated here as success or failure at contributing to some function or capacity of a mechanism.The vehicles of internal S-representations can be treated as components of cognitive mechanisms, and are targets of various cognitive operations. Each mechanism equipped with an S-representation as its component part underlies a certain phenomenon, i.e., some cognitive capacity. S-representations construed as mechanism components owe their functional characterization to how they contribute to the phenomenon that the larger mechanism is responsible for. What we mean by this is, essentially, that (M) X causes Y if and only if there are background circumstances B such that if some (single) intervention that changes the value of X (and no other variable) were to occur in B, then Y would change.  and it must not be correlated with any causes of Y other than X or those that lie on the causal route from X to Y.We now turn to the question of what it means for similarity to be causally relevant to success (or failure) thus understood. Here we aim to make use of James Woodward’s , 2008 poBy employing the interventionist view, we can now understand the causal relevance of similarity for success in the following way. The structural similarity between the representational vehicle and the target is causally relevant for success by virtue of the fact that interventions in similarity would be associated with changes in the success of whatever capacity that is based on, or guided by the representation in question. That is, manipulations on similarity would also be manipulations on the ability of the representation-user—be it a human being or some internal cognitive mechanism—to be successful at whatever she or it is employing the representation for.1, X2,…, Xn}, where each increasing value corresponds to an increased degree of similarity between the vehicle and the target. Therefore, between the lack of any similarity and a complete structural indistinguishability, there is a range of intermediate possibilities.To make this proposal more precise, let us apply (M) to the similarity-success relation. The variable X corresponds to similarity between the vehicle and what is represented. It would probably be a gross simplification if we treated X as a binary variable, with one value corresponding to the existence, and the other to the lack of similarity. Luckily, structural similarity can be easily construed as a gradable relation, depending on the degree to which the structure of one relatum actually preserves the structure of the another relatum  should result in systematic changes in the value of Y (which corresponds to the degree of success of the mechanism that makes use of an S-representation in performing its mechanistic function or capacity). In particular, by intervening in X so that its value increases, we should increase the value of Y; and by intervening in X so that its value decreases, we should decrease the value of Y.Before we move on, it needs to be noted that the relationship between similarity and success is nuanced in the following way. Good S-representations resemble relevant parts of the world only partially. Maps never mirror the territory in all its detail; instead, they are intentionally simplified, selective, and even distorted. The same applies to subpersonal S-representations. There are at least two reasons to think that. First, S-representations that resemble the target too much become excessively complex themselves. We should then expect there to be a trade-off between a representation’s structural complexity and the temporal or computational resources (costs) that real-life cognitive systems have at their disposal. It is doubtful that limited agents could generate S-representations that come even close to mirroring the structural complexities of the world. Second, in a world as complex as ours, generating maximally accurate S-representations tends to result in overfitting the data, which decreases the representation’s predictive value .This general observation can be expressed using our preferred interventionist framework. Suppose that increasing values of variable X correspond to increasing structural similarity between the vehicle and what is represented, and the increasing values of variable Y correspond to increasing success. Now, to accommodate our point, we may say that although in real-life cases of S-representation, there is a positive causal relation between X and Y, it only holds within a limited range of values of X. For simplicity, we may suppose that the relation holds from the lowest value of X to some specific larger value, but it disappears when X exceeds this value. That is, once the value of X exceeds a certain level, then (e.g. due to low cost-effectiveness or overfitting) its relationship to Y breaks down, e.g. increasing the value of X may begin to decrease the value of Y. Crucially, the lesson to be drawn here is not that similarity is functionally irrelevant, but simply that too much similarity can render the S-representation inefficient at serving its purpose. Our proposal is therefore that structural similarity is causally relevant only in a certain range, and the exact range depends on the overall structural trade-offs of the similarity-based system.The following empirical illustration should illuminate our view. In the philosophical literature, hippocampal spatial maps in rats have been proposed as a good example of an internal S-representation Ramsey . The ratonly insofar as it constitutes an intervention on similarity as such.As has been already argued in the literature, spatial navigation using hippocampal maps is an instance in which the structural similarity between the map and the territory is being actively exploited by the organism Shea . Similaras such that is causally relevant to success. Notice that it is impossible to perform an intervention on the similarity relation in any way other than by intervening in the structure of at least one of its relata . But this invites a worry. Would it not be much more parsimonious to simply state that what is causally relevant for success are structural properties of the vehicle and/or the target? After all, it is by intervening in either of them that we manipulate success. Why bother attributing the causal role to similarity itself? For example, to change a rat’s performance at navigating mazes, it will suffice to intervene on the hippocampal map. Why not simply say that it is the structure of the map  that is causally relevant to the rat’s success at spatial navigation? Why treat the relation between the map and the environment as causally relevant?The following issue might well be raised in the context of our mechanistic-interventionist treatment of the notion of exploitable similarity. One could wonder whether it is really similarity acts  and interventions that change the success of its actions. The change of action can, but does not have to change the success of the organism at whatever it is doing. If the change in the way the system acts is accompanied by an appropriate change in the external environment, the success can stay at the same level . At the same time, the same manipulation of action can change the success of the organism either by increasing it or decreasing it—again, the direction of influence will depend on properties of the environment . So there is no context-free, one-to-one correspondence between action and success. The reason for this is that success and failure in the sense we are using are essentially ecological categories. They co-depend both on what a given system is doing, and on the world within which it is doing it.To reply to this objection, we need to be careful to make the distinction between interventions that change the way some cognitive system actions . That much is not debatable. But manipulating actions is not the same as manipulating success. Because of this, the effect that the structure of the vehicle has on action does not imply that the same sort of relationship exists between the vehicle’s structure and success. It is impossible to say how manipulating the vehicle’s structure (and so the organism’s action) will change success independently of facts about the target; or more precisely, independently of the facts regarding structural similarity between the vehicle and the target. In other words, interventions on the vehicle’s structure change the success only insofar as they change the degree of similarity between the vehicle and the target. They increase success if they increase the structural fit between the vehicle and the target. They decrease success only if they decrease the structural fit. And they do not change the success if they do not bring about any change in the structural fit. In any case, what the success depends on is not just the vehicle, but also structural similarity. Of course, again, the only way to intervene on similarity is by manipulating the relata. But it is just wrong to conclude from this that similarity itself is not what is causally relevant here.Notice now that by concentrating solely on the properties of the representational vehicle, we would completely miss the point just made. Surely, interventions in the structural properties of the vehicle  would change the cognitive system’s not to similarity between the vehicle and the target, but to purely vehicular-structural properties of the representation. More precisely, imagine that each value of X corresponds to a different potential structural pattern of the vehicle, regardless of its relationship to anything outside the mechanism. The dependent variable Y remains the same, i.e., it measures the degree of success at realizing some capacity. Now, there are certain constraints that Woodward  could bring about drastically different results depending on external circumstances .Let us formulate our point using some technicalities of Woodward’s account of causal relevance. Suppose that the independent variable X corresponds Woodward  puts on similarity between the representational vehicle and the target. The relation between X and Y is then both systematic and stable. It is systematic because we can map increasing values of X onto increasing values of Y. And it is stable at least in the sense that it cannot be broken down by changes in the target. After all, the value of X itself partially depends precisely on properties of the target.Both Woodward’s constraints are however met if we go back to our original view and consider the variable X to correspond to the degree of if it is even justified to treat it as a representation  the detector enters this state as result of the temperature being 33°, (2) it switches the furnace into a state that is appropriate or functional given the temperature being 33°. The relation that this state bears to other states is irrelevant or accidental. To generalize, in detectors or indicators, the relations between alternative detector states need not replicate the relational pattern of the target. In this sense, the relation of structural similarity is epiphenomenal in their case: as such, it does not play a role in enabling the detector system to work properly.Regarding the first difference, let us reconsider the thermostat example. One can ascribe the structure to the bi-metallic strip because of the relations between different shapes that it can take depending on the surrounding temperature. But notice that for a system such as the thermostat, it is not structure  of the vehicle—and the resemblance that it bears to the target structure—plays a major role which is missing in the case of detectors.By contrast, an S-representation cannot do its job  without being structurally similar to the target. Here, the pattern of relations between components of the S-representation plays a crucial role. For example, a map—be it artifactual map or neurally-realized cognitive map—needs to stand in a structural resemblance relation to the terrain if it is to perform its S-representational job; and any figure placed within a map can act as an S-representational surrogate only insofar as it stands in certain relations to other figures or lines on the map. In other words, in S-representations, the functioning of S-representations from the way detectors function.The second difference that underlies the S-representation/detector distinction does not pertain to the nature of the relation that connects the representational vehicle to its target. Rather, it relates to what distinguishes the reacts to environmental cues. This is because her ongoing navigational decisions depend on what happens in the navigation system. What guides B’s actions are the system-derived anticipations and instructions, not the world itself. There surely are purely “receptive” aspects to using satellite navigation—B obviously needs to interact with the environment itself in order to verify satellite-based suggestions, and the system’s receiver must itself interact with the satellite to track B’s current position. However, there is an important sense in which person B’s actions are controlled by the satellite navigation itself, as opposed to being fully controlled by the terrain.Let us start with a simple illustration. Consider two people facing the problem of navigating their way from one location to another in a city. Person A has traversed this route many times in the past, to the point that she does not need to elaborately plan how to reach her destination. All that she has to do is to react, at appropriate times and in appropriate ways, to particular environmental cues and landmarks . Her navigational choices are fully dictated or determined by the territory itself: all that she does is respond to it in ways which enable her to eventually reach the destination. Now, person B has no previous experience with the city and so traverses the same route using satellite navigation. In the case of person B, it is not possible to explain her success at reaching the destination by simply pointing to how she causally selective in useful ways. Detectors tend to react exclusively to certain states of affairs, and, in turn, generate cognitive or behavioral responses that are appropriate given the circumstances. This the case with the thermostat as a detector-based mechanism: its bi-metallic strip reacts or responds to the target in a way that is useful to the larger mechanism. The way the thermostat behaves is under the control of the environment itself.Here is our point. The strategy employed by person A is representative of what is crucial, from a functional standpoint, to cognitive strategies that employ detectors. In detector-based strategies, the represented part of the world constitutes the locus of control of an action or a cognitive process. Detectors are functionally bound to their targets. This is because all the there is to working as a detector or indicator is to be One important thing to note here is that the “causal selectivity” at issue can be realized in ways other than through direct causal relation between the detector and its purported target. It could be established by indirect, mediated causal chain, or by the detector and the target sharing a common cause. In yet other cases, the detector may be causally related to a state which is merely spatiotemporally correlated with the target. Take, for instance, magnetosomes in magnetotactic bacteria. Magnetosomes react causally to the magnetic North; but given that the magnetic North is reliably correlated with the location of oxygen-free water, they can drive the bacteria towards its preferred environment. Here the detector is already causally disconnected from what it supposedly detects (the target). Still, its workings boil down to being reactive to the environment in useful ways.On the contrary, using S-representations is not a matter of simply selectively reacting to targets. In our toy example, this is apparent in person B’s case in that it is not the environment itself, but rather what happens in satellite navigation that constitutes the locus of control of the navigation process. To generalize this point, what is characteristic of S-representation-based strategies is that they employ an internal or endogenous source of control over action or cognitive processes; they are, so to speak, active, and not simply reactive strategies representing future and counterfactual states of affairs, there is no possibility—at least not without some serious metaphysical gymnastics—of saying that the representation is reactive to what is represented .One of the major consequences of S-representations’ being endogenously-controlled and functionally free in the sense described above is that they can naturally perform their duties even when the processes that they undergo do not correlate with any concurrent target or represented processes; that is, when the S-representation cannot be said to sufficient for this process to count as employing S-representation. Exploitable similarity needs to be involved.One might raise the question of how this functional story about S-representations relates to the story about exploitable similarity. To answer this issue, we need to note that being an endogenously-controlled process is not Let us elucidate this point by showing how structural similarity is exploited in cases of S-representations that are used off-line, this time concentrating on subpersonal representations of the sort that could feature in cognitive mechanisms. Three ingredients are involved in the off-line use of an S-representation thus construed. First, the S-representation is actively transformed or manipulated within the mechanism. That is, the S-representational vehicle undergoes an endogenously-controlled process in which its structure changes over time. The structure of the vehicle is being effectively put to use. Second, manipulations of this sort are employed by the larger mechanism to perform a certain function. For example, the effects of manipulations could serve (for some consumer component) as a basis for a decision about which course of action—out of some possible range—to take. Third, and crucially, the degree to which the effects of such manipulations of the S-representational vehicle’s structure are actually functional should depend causally on how well those manipulations and their outcomes resemble targets. That is, if they are to successfully guide action or cognition, the internal manipulations need to actually resemble or simulate how corresponding target processes would unfold.Take the rat’s spatial navigation system again. First, it has been suggested that place cells in a hippocampal spatial map can fire in sequences in a purely off-line manner, e.g., when the rat is asleep or is planning a route . The satellite navigation example mentioned before is a case in point: here, the S-representation controls an ongoing, direct interaction with the world . This point can be generalized to encompass purely subpersonal cases. Mechanisms can use S-representations to regulate on-line interactions with the environment. Imagine a cognitive system whose internal states change concurrently to changes in the external environment, and control behavior so that it is adaptive given the circumstances. Someone might, mistakenly, consider it to be a detector system, not that different from a simple thermostat. However, when we investigate the system’s workings, it turns out that its internal machinery is cut off from the target; it has no sensory apparatus. What explains its successful behavior is that it has an internal structure that continuously simulates the changing environment. This simulation is not a matter of responding to the target. Rather, it is an endogenously controlled process whose unfolding resembles the relevant dynamics in the environment, enabling the system to behave in accordance with the world it inhabits. The best, and, in fact, the only way to explain how the system manages to cope with the environment is to point to similarity between its internal processes and processes in the environment. Hence, despite working in a purely on-line manner, the system in question turns out to employ an S-representation of its environment.By concentrating on the off-line use, we do not mean to suggest that S-representations are mixed strategy which combines detector-based and S-representation-based ways of dealing with the environment on-line (as is the case in satellite-based navigation). What we mean is a system that simulates the environment but is at the same time equipped with response-selective detectors. The internal model could make predictions about the way the detectors will be affected by states of the world, with the mismatch between that prediction and feedback that is actually generated serving as a way of “measuring” the representational error. This sort of prediction-error-based cognitive strategy is postulated by recent predictive processing approaches to cognition  S-representations’ workings depend on the structural similarity in a way that is not the case with detectors, and (2) they constitute an endogenous source of control that exhibits a degree of functional freedom from states of the environment. Overall, we hope that our proposals further pave the way that leads away from seeing representations as a matter of reacting to the world detector-style, and towards the idea that representing the world is a matter of actively modeling it.Before we close the discussion, there is one last issue that merits mention. Some authors have argued that the domain in which S-representations can be explanatory is restricted to low-level cognition and that S-representations are not quite suited to explain more sophisticated, human-level cognitive capacities Morgan . Notice,


The realization of flat surfaces on the angstrom scale is required in advanced devices to avoid loss due to carrier (electron and/or photon) scattering. In this work, we have developed a new surface flattening method that involves near-field etching, where optical near-fields (ONFs) act to dissociate the molecules. ONFs selectively generated at the apex of protrusions on the surface selectively etch the protrusions. To confirm the selective etching of the nanoscale structure, we compared near-field etching using both gas molecules and ions in liquid phase. Using two-dimensional Fourier analysis, we found that near-field etching is an effective way to etch on the scale of less than 10 nm for both wet and dry etching techniques. In addition, near-field dry etching may be effective for the selective etching of nanoscale structures with large mean free path values. The use of optical near-fields (ONFs) has contributed to the progress of nanoscale optical measurements , nanosca2 gas for glass, GaN [2 gas for diamond and organic materials [Because the ONF can achieve dipole-forbidden transitions, we can create selective chemical reactions that occur only where the ONF has been generated. Using this concept, we have developed a near-field etching technique. In this process, the molecules are dissociated by an ONF with a lower photon energy than that of the molecules see . When liass, GaN , and plaaterials . AtomicaIn this study, we compared near-field etching using a solution (wet etching) as well as dry etching. To evaluate the ONF effect with respect to wet or dry etching, we examined the etching characteristics using a two-dimensional Fourier analysis.2 gas at a pressure of 200 Pa. 25 wt % calcium hypochlorous acid (Ca(ClO)2) was used as the source ion for wet etching. To dissociate the Cl2 or hypochlorous acid, we used a continuous-wave diode-pumped solid-state (DPSS) laser . Thus, the incident photon energy was lower than the dissociation energy of Cl2 (3.10 eV) [2 or hypochlorous acid dissociated on the protrusions only. In the solution, a light source with a photon energy of 4.66 eV (higher than the dissociation energy) dissociated the hypochlorous acid and consequently produced Cl radicals [2 gas is used. The laser light was incident from the top of the substrate through a chamber with 200 Pa Cl2 for dry etching or a drop of 10 μL Ca(ClO)2 (25 wt %) for wet etching  ; thereforadicals . This prhing see . The absRa) was found to be 0.161, 0.134, and 0.100 nm, respectively (solid circles in Ra where light was not irradiated with the Ca(ClO)2 solution and found that its value was unchanged  and P = 200 Pa). In contrast, the MFP of ions in solution is on the order of 10 pm [−7 times smaller than that of Cl2 gas. Such a low MFP value for ions in solution resulted in etching near the protrusions where the ions or molecules are dissociated. However, in the case of near-field dry etching, because of a greater MFP value of the gas phase that exceeds the scanning area, the dissociated atoms can react only when they are located at the protrusions where the ONF generated.To understand the differences of the etching properties, we estimated the mean free paths (MFPs) of Cl√2NAπd2P , where Rof 10 pm , which iUsing two-dimensional Fourier analysis, we found that near-field etching is effective for etching on smaller scales less than 10 nm for both wet and dry etching. In addition, by comparing wet and dry etching, near-field dry etching was shown to be effective for the selective etching of nanoscale structures because of the large value of the mean free path of the etching molecules. Hence, further control of the selective etching at smaller scales should be achievable by controlling mean free path .


We merged 2009 National Health Interview Survey data, American Nonsmokers’ Rights Foundation U.S. Tobacco Control Laws Database, and Census Population Estimates. Hazardous drinking outcomes included heavy drinking  and binge drinking (≥5 drinks on one or more days during past year). Chi-square tests compared hazardous drinking by sociodemographic factors. Multivariable logistic regression models were used to examine if smoke-free law and bar law coverages were associated with hazardous drinking, controlling for sociodemographics and smoking status. Subset analyses were conducted among drinkers who also smoked (n = 4074) to assess the association between law coverages and hazardous drinking. Among all drinkers, smoke-free law coverage was not associated with heavy drinking (adjusted odds ratio (AOR) = 1.22, 95% confidence interval (CI) = 0.99–1.50) or binge drinking . Smoke-free bar law coverage was also found to be unrelated to hazardous drinking. Similar results were found among those drinkers who smoked. Findings suggest that smoke-free laws and bar laws are not associated with elevated risk for alcohol-related health issues.Tobacco and alcohol use are strongly associated. This cross-sectional study examined the relationship of smoke-free law coverage and smoke-free bar law coverage with hazardous drinking behaviors among a representative sample of U.S. adult drinkers ( The paired use of tobacco and alcohol increases the risk for a variety of diseases, including cancers of mouth, throat, and upper aerodigestive tract ,2,3. HowHealthy People 2020 objectives is to enact 100% smoke-free laws in public places and worksites [Smoke-free laws are effective in protecting non-smokers from secondhand smoke ,16,17, rorksites . Given tHowever, very few studies have examined the effect of smoke-free laws on alcohol consumption or AUD, and the findings of existing research are inconsistent. Two longitudinal studies found that smoke-free bar laws did not change the frequency and/or amount of alcohol use overall, but reduced drinking quantity among moderate drinkers and heavy smokers ,30. AnotGiven the limited evidence regarding the relationship of smoke-free laws with alcohol use, we conducted this study to examine the association between smoke-free law coverage  and n = 17,057). Institutional review board approval is not required for this study, because it is a secondary analysis of de-identified NHIS data.We used county Federal Information Processing Standards (FIPS) codes to merge three databases: 2009 National Health Interview Survey (NHIS) restricted data, 2009 American Nonsmokers’ Rights Foundation (ANRF) U.S. Tobacco Control Laws Database, and 2009 Census Population Estimates . An FIPSAlcohol consumption was measured by three questions: “In any one year, have you had at least 12 drinks of any type of alcoholic beverage?” “In your entire life, have you had at least 12 drinks of any type of alcoholic beverage?” “In the past year, how many days per week, per month or per year did you drink any type of alcoholic beverage?” Consistent with the Centers for Disease Control and Prevention’s (CDC) definition ,37, respHazardous drinking, which included heaving drinking and binge drinking, was assessed among drinkers. Following National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines , respondAs described in detail elsewhere ,35, link’s definition [Current smokers were defined as smoking ≥100 cigarettes in their lifetime and smoking “every day” or “some days” now. Non-smokers included both never smokers (who smoked <100 cigarettes in their lifetime) and former smokers . Sociodemographic variables included gender, age , race/ethnicity , education attainment , some college, and college graduate), and poverty status . Following the US Census Bureaufinition , poverty® software programming code through ANDRE and receiving output via e-mail. Data were weighted to account for the complex sample design and to adjust for non-response and post-stratification [We had no direct access to the restricted NHIS data, because the FIPS county code is a restricted identification variable. Data were accessed through the CDC Research Data Center (RDC) . We usedfication . We usedn = 17,057), controlling for sociodemographic variables and current smoking status. We used multivariable logistic regression models among a subgroup of drinkers who reported current smoking (n = 4074) to examine the association between smoke-free law (and bar law) coverage and hazardous drinking controlling for sociodemographic variables.Separate multivariable logistic regression models were used to examine if smoke-free law coverage and smoke-free bar law coverage were associated with hazardous drinking outcomes among drinkers . Thus, findings reported in this study were the regression models without the interactions. We also tested the multivariable logistic regression models with state and region variables , and found that state and region did not change the association between smoke-free law coverage and hazardous drinking (significance level and direction). Therefore, we excluded the state and region variables in the final models. More details about calculating smoke-free law coverage score, merging data sets, data processing and model formulae can be found in We calculated the variance inflation factors (VIF) for all models, and the VIFs were between 1.012 and 1.192 indicating that multicollinearity was not an issue. The interaction of smoke-free law (or bar law) coverage score and current smoking were tested in the analysis among drinkers, and the interactions were not significant (p < 0.001), non-Hispanic whites (p < 0.001), people who did not graduate from high school (p < 0.001), those who were poor and near poor (p = 0.003), and current smokers (p < 0.001). Males and females were not statistically different in heavy drinking . Binge drinking was more common among men (p < 0.001), adults aged 21–24 years (p < 0.001), Hispanics and non-Hispanic whites (p < 0.001), people with less than high school education (p < 0.001), people who were poor and near poor (p < 0.001), and current smokers (p < 0.001). Over half (53.0%) of underage drinkers (aged 18–20) reported binge drinking.p = 0.055) or binge drinking  controlling for sociodemographic factors and current smoking status. Young adults aged 18–20 years were less likely to report heavy drinking than adults aged 45–64 years , but were more likely to report binge drinking . When substituting smoke-free bar law coverage for smoke-free law coverage, we found that smoke-free bar law coverage was not associated with heavy drinking  or binge drinking  among all drinkers (drinkers .p = 0.453) or binge drinking  controlling for sociodemographic variables (p = 0.782) or binge drinking  as well as the proportion of the county population covered by these laws. Thus, our measure of smoke-free law coverage captured both the dimension and the breadth of the laws.Smoke-free law (and bar law) coverage was not associated with hazardous drinking. Among the limited research about the effect of smoke-free laws on alcohol consumption , Young-Wolff et al.  found thSubgroup analysis revealed that there was no relationship between smoke-free law (and bar law) coverage and hazardous drinking among drinkers who smoked. Although we used a cross-sectional design, our finding was consistent with a longitudinal study that compared alcohol consumption between smokers who experienced smoke-free bar law implementation and other smokers who experienced no change in the law. Kasza et al.  found thThis study had several limitations. First, we used one wave of cross-sectional data. The study design did not allow causal conclusions on the relationship between smoke-free law coverage and hazardous drinking outcomes. Second, the study was based on self-reports, and thus was subject to recall and reporting bias. Third, our regression models were conducted based on the assumption that the relationship between independent variables and the logit of hazardous drinking was linear. A nonlinear relationship might exist between independent variables and outcomes. Fourth, our models did not control for all the factors that might affect alcohol use, such as alcohol tax and other alcohol-related policies. Thus, the result might under- or over-estimate the relationship between smoke-free law coverage and hazardous drinking outcomes. We did, however, assess logistic regression models that included state and region variables  and found that state and region did not change the association between smoke-free law coverage and hazardous drinking (significance level and direction). Fifth, there is no consensus on the definition of binge drinking. The NHIS used a gender-universal cutoff value to define binge drinking (≥5 drinks on at least one day during the past year). While the NIAAA used gender-specific cutoff values to define binge drinking (≥5 drinks for men and ≥4 drinks for women in about 2 h). Thus, the result might under- or over-estimated the binge drinking outcome.More longitudinal studies are needed to examine if and how county-level smoke-free laws affect alcohol use and other tobacco-related risky behaviors. It was also noteworthy that we defined heavy drinking as 14 drinks per week for men and 7 drinks per week for women, and defined binge drinking as having 5 or more drinks on at least one day in the past 12 months. For countries using other definitions for hazardous drinking outcomes, they may observe a different relationship between smoke-free laws and alcohol consumption. Future research that examines the impact of smoke-free laws on alcohol use should clarify how the outcomes of interest are defined.This is among the few studies that have examined the association between smoke-free laws and alcohol use among U.S. adults. Despite the limitations of using a cross-sectional design, our study contributes to the body of literature that asserts that smoke-free law and bar law coverages are not associated with hazardous drinking outcomes. It provides further evidence that policymakers can implement smoke-free laws to protect nonsmokers from secondhand smoke exposure (which contribute to reducing smoking) without increasing risk of alcohol-related health issues among drinkers.


Scientific Reports 10.1038/s41598-017-04801-7, published online 30 June 2017Correction to: In the original version of this Article, there were errors in Affiliations 6, 7, 8, 9, and 10 which were incorrectly listed as ‘School of Medicine, University of Louisville, Houston, USA’, ‘Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Houston, USA’, ‘University of Florida College of Medicine, Houston, USA’, ‘Cedars-Sinai Heart Institute, Houston, USA’, and ‘Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Houston, USA’ respectively.The correct affiliations are listed below.Affiliation 6School of Medicine, University of Louisville, Louisville, USA.Affiliation 7Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, USA.Affiliation 8University of Florida College of Medicine, Gainesville, USA.Affiliation 9Cedars-Sinai Heart Institute, Los Angeles, USA.Affiliation 10Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, USA.These errors have now been corrected in the PDF and HTML versions of the Article.


Online medical education has relevance to public health literacy and physician efficacy, yet it requires a certain standard of reliability. While the internet has the potential to be a viable medical education tool, the viewer must be able to discern which information is reliable.Our aim was to perform a literature review to determine and compare the various methods used when analyzing YouTube videos for patient education efficacy, information accuracy, and quality.In November 2016, a comprehensive search within PubMed and Embase resulted in 37 included studies.The review revealed that each video evaluation study first established search terms, exclusion criteria, and methods to analyze the videos in a consistent manner. The majority of the evaluators devised a scoring system, but variations were innumerable within each study’s methods.In comparing the 37 studies, we found that overall, common steps were taken to evaluate the content. However, a concrete set of methods did not exist. This is notable since many patients turn to the internet for medical information yet lack the tools to evaluate the advice being given. There was, however, a common aim of discovering what health-related content the public is accessing, and how credible that material is. In today’s world, the internet and social media are a part of everyday life. Within seconds, a handheld device can provide more information than one can possibly read. The ease and simplicity of finding information on the internet translates directly to answering health questions and concerns. By 2011, 59% of adults were looking up health information online, and internet access has expanded exponentially since then . Issues A thorough search was performed within both Embase and PubMed in November 2016. A data management librarian determined the search terms after a preliminary search to find which key words would supply relevant articles. Many search combinations did not generate any articles as this is a relatively new topic and YouTube was not created until 2005. Thus, our inclusion date for articles encompassed anything published after the year 2005. PubMed and Embase were chosen as the literature databases to search, as they are reputable sources of medical literature and PubMed also includes literature from the Medline database. The first search was performed in Embase with the term “patient education” AND “YouTube” OR “Online Videos” OR “Online video.” In PubMed, two separate searches were performed. The first search term was  AND (“YouTube” OR “online videos”), and the second search term was “YouTube health guidelines.” One author analyzed all of the included articles, and the results were reviewed and approved by another author. Each included article was read in its entirety, and the methods as well as unique characteristics for each study were recorded in MS Excel formatting and compared.The inclusion criteria for the studies to be reviewed were as follows: (1) analysis of videos intended for patients or guardians, (2) contains detailed and repeatable methods of analysis, (3) English language, and (4) analysis of videos that are made available to the public.The Embase search (“patient education” AND “YouTube” OR “Online Videos” OR “Online video”) generated 65 results, of which 20 were included for review. The first PubMed search  AND (“YouTube” OR “online videos”) had 77 results and 13 articles met the inclusion criteria. The last PubMed search  gave 16 results, of which 4 articles were reviewed. This resulted in a total of 37 studies to be reviewed see . Most exThis study was exempt from requiring Institutional Review Board approval.The same chronological process was generally followed within each piece of literature reviewed, but no two video evaluations were performed in an identical manner. The first step within each study included determining the search term(s) to be used. Multiple search terms were used to ensure that all possible patient searches could be evaluated. For example, “gallbladder disease,” “gallstone disease,” and “gallstone treatment” were all used to assess YouTube videos about gallstone disease, as they are likely terms used by the public . Other sMethods and techniques used to determine search terms and searching criteria for YouTube videos included multiple search terms (20 studies), autocomplete function within search bar, use of search operators, multiple search dates, limited number of pages within a particular search to be analyzed (30 studies), and changing the video results to be sorted by “most viewed” (3 studies).The next step involves determining which videos should be included in the study. Some researchers set a maximum time limit for included videos. Only one study excluded videos based on number of views, in which the videos were required to have greater than 2500 views . The preMost studies had multiple reviewers and stated the qualifications of the reviewers, which included students, residents, or physicians. The most rigorous qualification requirements involved a 1-month clinical rotation in the department of allergy and clinical immunology and successful completion of a series of learning objectives . The vidThe source of upload allowed for categorization of videos. An analysis of educational videos on children’s dental caries separated the videos into health care professionals, academic institutes, professional organizations, individual users, and product companies . These wJournal of the American Medical Association guidelines used, a point is given for authorship, disclosure, source, and currency of the video [To determine the accuracy of the videos, 22 of the studies created a novel scoring system. These scoring systems and other methods are summarized in he video . Health he video . Anotherhe video .Ten studies evaluated the quality of the video presentation, of which five assessed video quality according to global quality score guidelines. This rates the quality from a score of 1-5 while taking into account video flow and usefulness ,18. OtheThe most common video characteristics recorded were number of views, followed by source of upload. These data, along with the frequencies of other parameters taken into account by the various studies, are summarized in The most common sequence of methods performed is as follows: (1) determine a search term(s); (2) establish inclusion criteria for videos; (3) determine video reliability scoring/what parameters will be taken into account; (4) review videos individually; (5) convene to discuss discrepancies and determine final results; and (6) analyze results and determine the reliability or usefulness of videos and which characteristics determine that quality.Our review found that defining a search term, determining how to judge or score the videos, and determining the reliability of the video sources and information were the primary methods discussed throughout the studies. There were also many steps taken to ensure that the evaluations were indicative of how the general public and patients would receive and understand the information given in the YouTube videos. For example, YouTube content is constantly being modified, thus researchers performed content searches at later dates to give insight into the evolution of viewership . They alThroughout the reviewed literature, there was considerable focus on determining which video characteristics could be quantified and compared to reveal a positive correlation with video accuracy. The most commonly statistically analyzed parameters were video score versus number of likes, and video score versus source of upload. One study discovered that younger patients as well as patients with higher education are more likely to use the internet as source of health information due to their increased ability to search the Web and identify reliable information and sources . If videThis paper is a comprehensive review, but it is not a systematic review. All efforts were taken to include all articles possible, but we cannot guarantee that some were not missed. In addition, this is a newly popular topic and it is likely that use of these search terms at a later date will result in an increased number of results.Social media has the potential to aid in closing the health literacy gap and can present information in novel ways that allow even illiterate populations to learn . The Int


Early infant male circumcision (EIMC) has been identified as a key HIV prevention intervention. Exploring the decision-making process for adoption of EIMC for HIV prevention among parents and other key stakeholders is critical for designing effective demand creation interventions to maximize uptake, roll out and impact in preventing HIV. This paper describes key players, decisions and actions involved in the EIMC decision-making process.hypothetical and actual acceptability of EIMC in Zimbabwe. The first study (conducted 2010) explored hypothetical acceptability of EIMC among parents and wider family through focus group discussions . The follow-up study (conducted 2013) explored actual acceptability of EIMC among parents through twelve in-depth interviews (IDIs), four FGDs and short telephone interviews with additional parents (n = 95). Short statements from the telephone interviews were handwritten. FGDs and IDIs were audio-recorded, transcribed and translated into English. All data were thematically coded.Two complementary qualitative studies explored Study findings suggested that EIMC decision-making involved a discussion between the infant’s parents. Male and female participants of all age groups acknowledged that the father had the final say. However, discussions around EIMC uptake suggested that the infant’s mother could sometimes covertly influence the father's decision in the direction she favoured. Discussions also suggested that fathers who had undergone voluntary medical male circumcision were more likely to adopt EIMC for their sons, compared to their uncircumcised counterparts. Mothers-in-law/grandparents were reported to have considerable influence. Based on study findings, we describe key EIMC decision makers and attempt to illustrate alternative outcomes of their key actions and decisions around EIMC within the Zimbabwean context.These complementary studies identified critical players, decisions and actions involved in the EIMC decision-making process. Findings on who influences decisions regarding EIMC in the Zimbabwean context highlighted the need for EIMC demand generation interventions to target fathers, mothers, grandmothers, other family members and the wider community. Early infant male circumcision  has been identified as a key HIV prevention intervention for sustaining the prevention gains anticipated through adult voluntary medical male circumcision (VMMC) –3. AlthoIn addition, EIMC is cheaper than VMMC, with studies estimating that it is likely to be a cost-saving HIV prevention intervention in the longer term –10. ProjZimbabwe has provided VMMC to around 750,000 adult and adolescent men. The program aims to reach 1.3 million 15-29 year-olds by 2017/18. Zimbabwe also intends to offer EIMC alongside VMMC , 22. Sinhypothetical acceptability of EIMC among parents and the wider family through focus group discussions (FGDs)  and you reach a consensus’ . In the second study, which explored actual acceptability of EIMC, accounts surrounding EIMC uptake also suggested that the decision-making process had involved a discussion between the infant’s parents. A mother described events leading to their son’s circumcision.I listened to a lady who talked about EIMC when I was still pregnant. I took a pamphlet she had given me home, gave it to my husband and we discussed the issue. My husband said that it was a good thing. He said if I gave birth to a baby boy, we were supposed to take him for circumcision immediately after birth. When I gave birth to a baby boy, I simply went ahead … .…In the first study, which explored In my case we discussed the issue since we had never heard of it [EIMC]. We agreed that our son might benefit… it was an “experiment”…’ . Another male participant described the danger associated with making a unilateral decision in respect of newly-introduced initiatives. ‘…Especially for something that is new, if you want to exercise your powers on something you don’t know, you will end up shouldering the blame’ . It appears that as EIMC was a new initiative, men did not feel confident about overriding their wife’s decision in the way that they might for other decisions.Some male participants also stated that the decision to circumcise their son had involved some discussion. ‘The man must make that decision because he is the one who knows whether or not that is practiced in his clan; a woman cannot know anything about a clan to which she doesn’t belong’ . The implication here is that if male circumcision is not practiced in the father’s clan it would not be advisable to circumcise the male infant. A female participant concurred, ‘As the mother, I cannot decide whether or not the child should be circumcised. I will need to “sit down” [discuss] with the father and we will have to go by his decision’ . This sentiment was echoed by one father, ‘The decision to circumcise my son rests with me. I’m the one who tells the wife what to do’ .Nonetheless, in both studies, male and female participants of all age groups acknowledged that the father has the final say. ‘If you were not interested [in EIMC] you could lie to him [baby’s father] that a neighbour had her son circumcised and something undesirable happened. If you were interested, you could also lie to him that several neighbours had their sons circumcised and everything went on well .Even though the father was deemed to have the final say, discussions around EIMC uptake suggested that mothers of newborn babies took advantage of men’s anxiety about decision-making to influence the outcome. As one mother described,‘I told him that I would go to the rural areas and leave him with the child if he went ahead with the circumcision and he backtracked’ [laughter] .Another mother described how she had successfully threatened her husband. Where does the [infant’s] mother fit in?’ . He went on to proclaim, ‘The mother of the child is also my child’ . This sentiment was echoed by an older woman. ‘The daughter-in-law will not refuse; I have powers over the grandchild…I will take him for circumcision myself’ . Discussions also suggested that the wider family’s influence is sometimes covert. An expectant mother described steps she would take if her husband refused to have their son circumcised if that was what she wanted. ‘If he [father] refuses, I will talk to his mother and she will then ask his uncles to talk to him’ .Although both studies suggested that the infant’s parents are the key decision makers, subsequent probing suggested that mothers-in-law/grandparents are also likely to have considerable influence. In the first study, when elderly men were asked what they would do if a daughter-in-law turned down a suggestion to circumcise her son, one of them questioned, ‘‘She said, “I have never heard of it. All of my sons are uncircumcised and even my husband wasn’t circumcised”’ . Responses to short telephone interviews confirmed FGD and in-depth interview findings with regards to the mother-in-law’s centrality in the EIMC decision-making process. Of the 18 instances where telephone interview respondents mentioned the actual person who had said the male infant should not be circumcised, in 50% of the cases it was the infant’s father, followed by the infant’s mother (28%) and the mother-in-law (22%).Findings from the subsequent study corroborated those from the earlier one with regards to the role of the wider family in the EIMC decision-making process. Parents stated that they had consulted other family members prior to adopting EIMC. Barring the decision by one or both parents, the mother-in-law’s perspective was instrumental in adoption or non-adoption of EIMC. A mother who did not adopt early infant male circumcision described how her husband’s mother had shot down her proposal to adopt EIMC. …She really welcomed the idea because she has got nursing friends so she knows that HIV is resulting in this and that. So she was quite supportive; she even asked what I was thinking about our first child. He is three years old now and she said, ‘What are you going to do with this one?’ So she had no problems with us circumcising the newborn .Mothers-in-law did not always block EIMC; they were sometimes quite supportive. A male participant described how his mother had supported EIMC.It appears that if the mother-in-law had some MC and HIV knowledge, she was likely to encourage her son and daughter-in-law to adopt EIMC.Triangulating findings from the two studies described here, we have come up with an EIMC decision tree in an attempt to illustrate the most commonly described decision-making process uncovered during discussions. We present key decision makers as well as alternative outcomes of their key actions and decisions around EIMC within the Zimbabwean context. In summary, based on study findings, we have illustrated that when the mother becomes aware of the possibility of EIMC for her newborn son, she either keeps quiet or misinforms the infant’s father about the risks of EIMC if she does not want to have her baby circumcised. On the other hand, if she wants to have her son circumcised, she informs the father about the possibility of EIMC and a discussion of the pros and cons ensues. If the father objects to EIMC, the baby will not be circumcised (unless the infant's mother covertly influences EIMC adoption). However if the father is interested, he will consult his own mother (wife’s mother-in-law) and/or wider social support network whose views may or may not influence the ultimate outcome Fig. . The maiWe utilized data from two complementary qualitative studies to unpack EIMC decision-making within the Zimbabwean context. This enabled us to identify key decision makers as well as alternative outcomes of their key actions and decisions around EIMC.Data highlight the crucial role fathers play in EIMC decision-making. These findings are consistent with those from other settings –30. A stdirectly not just through their wives. Given that men are notoriously hard to reach via health services [On the whole, the findings from the studies presented here, coupled with those from other settings, suggest that since fathers make the ultimate decision as to whether their infant son should be circumcised or not, they need to be provided with information services –33, otheservices . These fAn attempt to map the EIMC decision-making process — especially within the context of a research initiative — is extremely challenging. Despite adult VMMC scale-up in the 14 priority countries over the last 4–5 years, researchers have not yet managed to adequately dissect the adult VMMC decision-making process. Some research groups have attempted to do this and have identified some of the important factors while acknowledging that their understanding of the process is incomplete –36. TheyBy better understanding the motivating factors, messages to influence uptake of adult VMMC have been redesigned. For example, VMMC in Zimbabwe has been repackaged as a lifestyle choice rather than an HIV prevention method so as to increase acceptance of the service by both men and women, in addition to countering perceptions that the procedure only benefits “promiscuous” men . This haDespite the difficulty in unpacking the VMMC decision-making process, it is generally accepted that decision-making is characterized by an interplay of various factors at the individual, household and community levels . Additiohypothetical and actual EIMC decision-making. That there was concordance between data obtained from the two studies points to the likely validity of the findings presented here. Also, the studies triangulated various data collection methods . With specific reference to qualitative research, triangulation has been widely adopted as a means of investigating the validity of both the data and the conclusions derived from them [Data presented here are from two complementary studies that explored both rom them . In thisn = 12), FGDs (n = 4) and short telephone interviews (n = 95) based on pragmatic considerations. It could be argued that parents with newborn sons who declined to participate in the EIMC trial (n = 984) were not adequately represented in this relatively small qualitative piece. Also, it is possible that we did not manage to adequately map the EIMC decision-making process especially since we attempted to do this within the context of a research initiative.A potential limitation is that for the second study, we conducted a predetermined number of in-depth interviews (The complementary studies described here enabled us to explore both hypothetical and actual EIMC decision-making among parents and the wider family. Findings will likely be useful in informing targeted demand creation initiatives to support wider adoption of EIMC. Although issues related to EIMC decision-making are to some degree context specific, some of those identified in these studies may apply in other regional settings intending to roll out EIMC.


Malnutrition is an independent risk factor for patient morbidity and mortality and is associated with increased healthcare-related costs. However, a major dilemma exists due to lack of a unified definition for the term. Furthermore, there are no standard methods for screening and diagnosing patients with malnutrition, leading to confusion and varying practices among physicians across the world. The role of inflammation as a risk factor for malnutrition has also been recently recognized. Historically, serum proteins such as albumin and prealbumin (PAB) have been widely used by physicians to determine patient nutritional status. However, recent focus has been on an appropriate nutrition-focused physical examination (NFPE) for diagnosing malnutrition. The current consensus is that laboratory markers are not reliable by themselves but could be used as a complement to a thorough physical examination. Future studies are needed to identify serum biomarkers in order to diagnose malnutrition unaffected by inflammatory states and have the advantage of being noninvasive and relatively cost-effective. However, a thorough NFPE has an unprecedented role in diagnosing malnutrition. Malnutrition presents a substantial socioeconomic challenge in today’s healthcare landscape with an estimated prevalence of 30–50% . The prevs 4.7% in the well-nourished patients (RR = 2.63). Similarly, another study of 104 patients with acute stroke of < 24 hours duration reported that malnourished patients were more likely to have higher stress reaction, increased frequency of infections and pressure ulcers compared with the appropriately nourished group [Malnutrition is associated with an increased risk of major and minor complications as well as an increase in direct and indirect costs. One retrospective study of 709 adult patients from 25 Brazilian hospitals reported that the incidence of complications in the malnourished was 27% (relative risk [RR] = 1.60) compared with17% in the well-nourished counterparts . Furthered group . Additioed group . Indirecet al. as “decline in lean body mass with the potential for functional impairment” [A major obstacle for diagnosing malnutrition is the lack of a unified definition of the term. Furthermore, there is no standard method for screening and diagnosing patients with malnutrition, leading to confusion and varying practices among physicians across the world. The appreciation that inflammation plays a major role in the pathophysiology of malnutrition is also lacking. Overall, this has led to a lot of misdiagnoses and a general under-recognition of the importance of malnutrition . An all-airment” . This imairment” .There are a number of tools that are used to assess the characteristics of malnutrition. This paper will focus on two of the frequently used malnutrition assessment tools—laboratory data (serum markers) and physical examination —and compare them to assess which is more useful in a clinical setting.Historically, serum proteins such as albumin and prealbumin (i.e. transthyretin) have been widely used by physicians to determine patients’ nutritional status . Other mAlbumin is a serum hepatic protein with a half-life of 14–20 days. It functions as a carrier molecule for various minerals, hormones and fatty acids and also helps to maintain oncotic pressure in the capillaries . More thThe concept of “stress-induced hypoalbuminemia” is somewhat controversial, but it demonstrates the concept of the body’s normal physiological response to injury. Since there are a multitude of disease processes that alter the level of albumin, it becomes an unreliable serum marker for malnutrition. This is especially true in acute healthcare settings, where a number of infectious and inflammatory states alter the serum concentration of albumin. Despite this, physicians frequently rely on albumin levels to gauge a patient’s nutritional status.However, there is some contrary evidence that measuring albumin levels may be a useful tool for diagnosing malnutrition, especially in cardiac transplant and orthopedic patients. In one study of 60 cardiac transplant recipients at least five years post transplant, serum albumin was found to be a better predictor of underlying malnutrition than body mass index (BMI) and subjective global assessment (SGA) . SimilarThe evidence is weak for using serum albumin as a marker of malnutrition in non-inflammatory states such as starvation. A meta-analysis of 63 studies, which included 2125 patients and investigated the effects of starvation on serum albumin levels in otherwise healthy individuals, reported that the levels remained normal until the patients reached extreme states of starvation (BMI < 12 or length > 6 weeks of starvation) when the malnutrition was already physically evident. Hence, it was concluded that albumin cannot be reliably used as a marker for diagnosing protein-calorie malnutrition . SimilarThere has been much debate regarding the role of albumin as a measure of nutritional status in the non-acutely ill geriatric population with low functional capacity. One study found that using serum albumin levels < 3.5 g/dL as the sole parameter for malnutrition would have low specificity for identifying nutritional status in the functionally impaired elderly . It woulSimilar to albumin, prealbumin (PAB) is also a negative acute-phase protein produced by the liver. Thus, it is affected by some of the same inflammatory states such as infections and liver disease. However, there are a few key differences between these two proteins. The half-life of PAB is much shorter (2–3 days), and its total body pool is considerably smaller than albumin. Both of these factors theoretically allow it to be used as a more reliable indicator of acute changes in a patient’s nutritional status. However, PAB is degraded by the kidneys, and consequently any renal dysfunction causes an increase in its serum levels. Furthermore, one of the functions of PAB is to act as a transport protein for thyroxine. In hyperthyroid states, the molecules of prealbumin are saturated with thyroxine, and hence the measured serum levels of PAB are low. Similarly, PAB levels are high in hypothyroid states .Transferrin is a serum protein and yet another negative-phase reactant that has been used to determine nutritional well-being . Inaccuret al. investigated the role of PAB in 45 consecutive head-injury patients admitted to the intensive care unit (ICU) and found that PAB was the most sensitive serum marker for the early diagnosis of malnutrition and for assessing the appropriateness of the nutritional therapy for malnourished patients [et al. reported that PAB was a better indicator than albumin for assessing the adequacy of postoperative nutritional support [RBP mainly exists as a part of the retinol-circulating complex. Vitamin A and zinc are vital in the proper functioning of RBP, and hence any abnormalities in the levels of these micronutrients affect the levels of RBP in the serum. Also, the entire complex is degraded by the kidneys, and thus renal insufficiency increases the levels of RBP . One stupatients . Similar support . They foBecause of the recent advancements in understanding the role of inflammation in malnutrition, several inflammatory mediators have been studied as serum markers. One such molecule is CRP, which is a positive acute-phase reactant . However3 correlate well with malnutrition, and those < 900/mm3 reflect severe malnutrition [TLC is another popular serum marker with proposed usefulness for determining nutritional status. Levels of TLC have been shown to vary with the degree of malnutrition. Levels < 1500/mmutrition ,34. Howeutrition .The historical gold standard for assessing protein intake is nitrogen balance. It is calculated as nitrogen intake minus nitrogen loss from the body and is useful for evaluating protein metabolism because nitrogen is an essential part of protein building blocks– amino acids. A negative nitrogen balance means there is more loss than intake, which can be used as a marker for assessing malnutrition . NitrogeThe nutrition-focused physical examination (NFPE) is an essential component for diagnosing malnutrition. Focusing on general characteristics such as edema, muscle wasting and subcutaneous fat loss to specific micronutrient related deficiencies, the NFPE is very sensitive for assessing nutritional status. The SGA is a well-validated tool for assessing malnutrition, especially in hospitalized patients. It includes several physical examination assessments such as muscle wasting and subcutaneous fat loss .The SGA is a well-validated, bedside tool for recognizing malnutrition ,38–43.Thet al. performed and validated the SGA on 175 patients admitted to the medical-surgical gastroenterology service [et al. recruited 53 patients from long-term care facilities and reported a significant correlation between SGA scores and nutritional complications including death [Several studies have employed the SGA in their patient cohorts and reported great validity and reliability in diagnosing malnutrition . Hirsch  service . They alng death . Hence, et al. introduced the original SGA, there have been numerous modifications and versions proposed for a variety of reasons [et al. reported that the PG-SGA score had a sensitivity and specificity of 98% and 82%, respectively, for predicting SGA classifications [et al., in their study of 60 patients on hemodialysis, reported that a PG-SGA score ≥ 9 had a sensitivity and specificity of 83% and 92, respectively, for predicting SGA classification [Since Detsky  reasons . The pat reasons . It inclications . They cofication . There wOther versions of the SGA include the dialysis malnutrition score and malnutrition-inflammation score (MIS). The MIS is unique in that laboratory measures such as serum albumin and total-iron binding capacity are also included in the standard SGA. Few studies have reported the MIS score having significantly higher correlations with actual nutritional status of patients as compared with the conventional SGA ,55. HoweA decline in subcutaneous fat and overall body muscle mass is a significant indicator of malnutrition ,57. As pThe pathophysiology of malnutrition-related muscle atrophy is fairly well-delineated. During times of severe nutritional derangements and stress, decreasing glucose concentrations result in decrease in insulin and increase in glucagon levels . This stEvaluations of muscle mass and subcutaneous fat tissue have been reported to be reliable, as have noninvasive tests for assessing nutritional status. In a cross-sectional study of 262 patients referred to nutritional support teams, 94% of the patients had previous physical examinations to determine loss of fat and muscle mass, which indicate regular use of nutritional assessment in clinical care settings for the diagnosis of malnutrition prior to the referral . Anthropet al. compared skinfold thickness to dual-energy X-ray absorptiometry (DEXA) to evaluate body fat [et al. analyzed skinfold thickness in 30 patients undergoing hemodialysis and concluded that this method was comparable to the reference method DEXA and preferred over bioelectrical impedance analysis (BIA) [The reliability of upper arm measurement as a nutritional assessment tool has been demonstrated in several studies. In 40 cirrhotic patients, Fiore body fat . The autis (BIA) . Hence, Malnutrition has also been well correlated with a decrease in muscle strength and overall functional status . Physiolet al. reported a significant decline in voluntary HGS in malnourished patients compared with their well-nourished counterparts (45.22 kg vs 30.82 kg in men) [et al., in their study of 72 young adult males reported that, HGS was able to differentiate between underweight and chronically energy-deficient patients with similar BMI regardless of total body cell mass [Several studies have demonstrated the importance of measuring HGS for diagnosing malnutrition in the hospital setting . In a st in men) . HGS corell mass . Lastly,ell mass . HGS meaell mass .et al. provided nutritional supplementation to 36 patients within 2 weeks of starting anti-tuberculous therapy [P= 0.016) at 6 weeks. Similar results were obtained in a study of 124 high-risk acute stroke patients randomized to either individualized nutritional care or routine hospital care [The importance of HGS in malnutrition has also been demonstrated by the recovery of muscle function upon nutritional intervention . Paton e therapy . Physicatal care . In respThe A.S.P.E.N. guidelines for diagnosing malnutrition, which looked at six characteristics, were first proposed in 2009 . At leasA thorough physical examination is necessary to look for specific signs of muscle and fat loss. During severe wasting states, the temples may become hollowed. In addition, ribs may start protruding in the clavicle/pectoralis muscle areas. Muscles in the lower body are more resistant to change, but clinicians should assess the posterior calf and anterior thigh areas by grasping the muscles. Similarly, signs of subcutaneous fat loss include hollows and dark circles in the orbital region, obvious depressions between the ribs and a prominent iliac crest. Examination for the accumulation of fluid should start by assessing a patient’s overall fluid status. This will be especially difficult in patients with diseases such as congestive heart failure, cirrhosis or renal failure. Areas that should not be missed during the examination are the face, abdomen, extremities and scrotum. Pitting edema of 1+, 2+, 3+ and 4+ correlate with 2mm, 4mm, 6mm and 8mm depression, respectively. Diminished functional status is usually assessed with HGS using a dynamometer. It must be remembered that patients with rheumatoid arthritis, stroke and any neuromuscular diseases in addition to those in the ICU may not be able to give valid measurements. If HGS cannot be performed, physicians can use other parameters  to determine patients’ functional ability.Pros and cons of some frequently used serum markers are summarized in Conflict of interest statement: none declared.


They also argue that making video recording a routine occurrence would improve performance and make surgical care more transparent. They propose that a video archive of operations could prove useful for surgeons preparing to operate on a patient who had been operated on before—to check the anatomy and density of adhesions for example. It has also been suggested that when used routinely, video could be used to investigate adverse events.4–6Recently, Makary research. While videos can only provide a partial representation of what happened and are always open to interpretation, they do provide a relatively objective, shareable point of reference. Using video, clinical events can be looked at from different angles. In suitably equipped operating rooms, the laparoscopic camera and light handle cameras provide a detailed view of the operative field, while wall-mounted cameras capture the entire multiprofessional team in action. In-built microphones and wireless microphones worn by members of the team can be used to record verbal communications.What has gone relatively unnoticed in these recent discussions about the potential of video in the operating room is the possibilities it opens up for empirical collecting live data. Such data can provide alternative or complementary data to that gained through interviews, where team members provide a retrospective account of events based on their memory of what took place. Video enables different team members, external observers and analysts to review segments of an operation repeatedly, zooming in and slowing down where relevant, so as to verify each other's judgements and interpretations and develop a shared understanding of what took place.Thus, video recording has now become a relatively cheap, accessible yet powerful method for methodological frameworks. One such framework was developed by Iedema et al.However, using video as data for patient safety research demands apt microanalysis conducted by a multiprofessional team of analysts using specialist software. The framework offers tools for systematically describing, analysing and, ultimately, predicting behavioural patterns. It is unique in that it operates on a ‘microscopic’ level, highlighting human actions—spoken utterances, gestures, gaze shifts—involved in clinical events and illuminating the ways in which they are interwoven, taking full advantage of the fine detail offered by the video record.The methodological framework we introduce here combines elements from sociolinguistics, conversation analysis and social semiotics. It brings new insights into clinical practice by detailed, systematic The framework has been used in a range of studies on  work environments, including surgery, anaesthesia, dentistry and emergency medicine.Our approach rests on the tradition of naturalistic inquiry, where fieldwork is conducted to observe behaviour in actual clinical settings rather than experimental controlled settings.We adopted this approach in a series of studies, investigating communication, situation awareness, teamwork, clinical decision making and surgical education in the operating rooms of a major hospital in London. Ethical approval was granted by the UK National Health Service Research Ethics Committee (ref nr 10/H0712/1). From 2010 and 2013, we audio and video recorded 42 operations, covering 66 hours of operating time. Procedures included a mix of general surgical, upper gastrointestinal, colorectal and bariatric procedures. These ranged from simple skin lesion excisions under local anaesthetic to major cancer operations taking an entire day. A wireless microphone was worn by one of the surgeons. Video recordings were collected using a camera built into a light handle, camcorders mounted on tripods and (where relevant) the laparoscope. All participants were aware that data were being collected to study behaviours in the operating room but no evidence was found in the video data that participants responded adversely to the presence of cameras. Key to the analytical process was the repeated inspection, transcription and coding of verbal and non-verbal communication to produce a detailed time log .Professional transcription and annotation software is available to support this logging and coding process . Quality control in our studies was achieved by having multiple researchers code a sample of the video recordings and compare and discuss any differences. In this way, transcribers developed a shared understanding of the codes used.When systematically coded, logs can be used for three different analytical purposes.prevalence of certain behaviours within the sample. For instance, in one studymeasured the time lapse between the completion of the verbal request, the clarification and the passing of the required instrument by the nurse  provide an empirical point of reference for and promote discussion about surgical practices, (b) present key findings from our research on behaviour and communication in the operating room and (c) verify the extent to which these findings resonate with our audiences.For instance, we showed video clips illustrating the loudness of music sometimes played at our research site to highlight occasional challenges experienced by nurses in hearing what surgeons were requesting. The clips provided evidence of the impact that music can have on surgical teams, and prompted discussions exposing a range of views among clinicians and publics around the pros and cons of playing music during surgery.We have also used recordings to develop Video-Supported Simulation for Interactions in the Operating Room.large video database. Before data can be collected on such a scale, there are ethical and medicolegal issues to be addressed.The examples outlined above indicate that detailed analysis of video holds significant potential for improving patient safety. Further use of video research will benefit from a mixed methods research. One potential area is to explore correlations between the detailed breakdowns of observed behaviour illustrated in this viewpoint and conventional global ratings based on existing observation tools. This could help make explicit exactly what raters believe to be indicators of ‘good’ practice, specifying relatively vague descriptors in observation tools, such as ‘the communication was clear’. These specifications could be used to develop a specialist language for talking about and reflecting on clinical work. Associations could also be made between the occurrence of patterns of communication and patient outcomes.Video recording within surgery offers rich possibilities for data collected using other digital technologies. Eye-tracking glasses can be used to gather detailed information about team members' focus of attention,Video recordings can be usefully supplemented with Possibilities for exploring behaviours and their relations to the room environment and patient outcomes are greatly expanded with the introduction of integrated systems or ‘black boxes’.Though the focus of this paper is the operating room, we believe that opportunities for microanalysis of video exist across different areas of healthcare. Of course video has been used by social scientists to study clinical practice for decades, and there is significant methodological expertise in this area. Yet to date, little video research of the kind presented here, with its detailed analysis of behaviour and interaction, has directly addressed issues around patient safety; it has, by and large, been designed for social scientists rather than for health professions. It is time for health professionals and patients to take advantage of this approach, and for existing methodological expertise to be unlocked, applied and advanced for the benefit of all.