We characterized the regulation of Mg2+ efflux by glucose in ex vivo human RBC. We observed that hemoglobin A1C (HbA1C) values correlated with Na+-dependent Mg2+ efflux (Na+/Mg2+ exchange) and inversely correlated with cellular Mg content. Treatment of cells with 50 mM D-glucose, but not with sorbitol, lowered total cellular Mg  and enhanced Na+/Mg2+ exchange activity . In contrast, incubation with selective Src family kinase inhibitors PP2 or SU6656 reduced glucose-stimulated exchange activation (p < 0.01). Na+/Mg2+ exchange activity was also higher in RBC from individuals with type 2 diabetes  than from non-diabetic individuals . Increased Na+/Mg2+ exchange activity in RBC from T2D subjects was associated with lower intracellular Mg content. Similarly increased exchange activity was evident in RBC from the diabetic db/db mouse model as compared to its non-diabetic control (p < 0.03). Extracellular exposure of intact RBC from T2D subjects to recombinant peptidyl-N-glycosidase F (PNGase F) reduced Na+/Mg2+ exchange activity from 0.98 ± 0.14 to 0.59 ± 0.13 FU (p < 0.05) and increased baseline intracellular Mg content (1.8 ± 0.1 mM) to normal values . These data suggest that the reduced RBC Mg content of T2D RBC reflects enhanced RBC Na+/Mg2+ exchange subject to regulation by Src family kinases and by the N-glycosylation state of one or more membrane proteins. The data extend our understanding of dysregulated RBC Mg2+ homeostasis in T2D.Hyperglycemia is associated with decreased Mg The mulver time . HbA1c ile cells .2+ efflux through activation of Na+/Mg2+ exchange in ex vivo RBC from humans with type 2 diabetes (T2D) and otherwise healthy individuals, as well as in a rodent model of T2D. We also show that RBC from T2D subjects have lower cellular Mg content and increased baseline Na+/Mg2+ exchange activity as compared to cells from normal control subjects. Treatment of RBC from T2D subjects with extracellular N-glycosidase increased cellular Mg content and decreased Na+/Mg2+ exchange activity to non-diabetic control levels. Thus, our results suggest that RBC protein glycation adducts and protein N-glycans directly or indirectly modulate Na+/Mg2+ exchanger activity, contributing to dysregulation of Mg2+ homeostasis in T2D.We now present evidence that glucose modulates erythrocyte Mg levels by stimulating MgMaterials: A23187, bovine serum albumin , choline chloride (Choline Cl), PP2 and SU6656 were purchased from Calbiochem . Wortmannin (WT) was from Alexis Corp. . Dimethyl sulfoxide (DMSO) was from Fisher Scientific . Acationox was from Baxter Scientific Products . All other reagents were purchased from Sigma Aldrich .Isolation of Red Cells: Human blood samples were obtained between 7:00 a.m. and 10:00 a.m. after overnight fast (>6 h) per approved clinical protocol and processed within 3 h of receipt, as previously described (1c) was measured by Hitachi 917 autoanalyzer (Manheim/Boehringer). Total intracellular contents of Na, K, and Mg were measured by atomic absorption spectrophotometry (Perkin Elmer 800). To avoid changes in mean cellular volumes (MCV), mouse blood was prepared as specified for human RBC, but in solutions adjusted to the osmolarity of normal mouse plasma (330 mOsm).escribed . BrieflyCellular Mg2+efflux measurements: Cells were loaded with Mg2+ as we previously described (2+/Mg2+ ionophore A23187 in Mg2+-loading solution (MLS) containing (in mM) 140 KCl, 12 MgCl2, 10 D-glucose, and 10 Tris MOPS (pH 7.4) for 30 min at 37°C. To obtain a range of different intracellular Mg concentrations in 2 concentrations between 0 and 16 mM, with corresponding KCl concentrations between 138 and 158 mM. A23187 was subsequently removed with four washes of 25 volumes of 0.1% BSA in MLS at 37°C at 15 min intervals. Mg2+-loaded cells at 3% hematocrit were incubated at 37°C for periods of 5 or 45 min in NaCl or choline choline chloride flux media containing (in mM) 140 NaCl or 140 choline Cl, 10 D-glucose, 10 Tris MOPS (pH 7.4), 20 sucrose, 0.1 ouabain, and 0.01 bumetanide. Mg2+ efflux was calculated from the slope of linear regression analyses of Mg content  in supernatant vs. time (5 and 45 min in triplicate determinations). Na+/Mg2+ exchange activity was calculated as the difference between Mg2+ efflux in NaCl and in choline Cl flux media. Flux values were corrected for changes in mean corpuscular volume (MCV) and expressed as mmol/1013 cells × h , as previously described : 140 NaCl, 0–100 D-glucose, 10 Tris MOPS (pH 7.4), 0–20 sucrose, 0.1 ouabain, and 0.01 bumetanide, with the indicated concentrations of D-glucose or sorbitol. Incubated RBC were centrifuged 5 min at 2,500 rpm at 37°C and suspended in Mg2+-free choline wash solution as previously described (2+) remain unchanged under these conditions. We observed no hemolysis after 24 h incubation of RBC in the presence of 50 mM glucose. We noted trace hemolysis after 24 h incubation in the presence of 100 mM glucose, but no further hemolysis was evident in RBC after resuspension in flux medium. Aliquots of 50% suspension were taken for measurements of Mg2+ efflux and total cellular contents of Mg, K, and Na as described above. We also studied the effects of Peptidyl-N-Glycosidase F (PNGase F), an amidase that cleaves the GlcNAc-asparagine linkage of high mannose and complex oligosaccharides of N-linked glycoproteins . Normal (n = 33) and T2D individuals (n = 30) were recruited at the Brigham and Women’s Hospital. Informed written consent was obtained from all subjects before participation. T2D was diagnosed according to accepted guidelines . Diabetic participants were not being treated with antihypertensive or any other medication except for medication related to their diabetes. Not all subjects were studied in all analyses, and subjects were not matched for clinical characteristics. Subjects varied in age between 22 and 62, with body mass index (BMI) <31 kg/m2 for women or <33 kg/m2 for men. Diabetic and control groups did not differ significantly in age.db/db Mice: All mouse studies were conducted under protocols approved by the Institutional Animal Care and Use Committee of Brigham and Women’s Hospital. db/db mice  and heterozygote controls  were purchased at 6 weeks of age, fed ad libitum with rodent chow  and water, then sacrificed and venisected by intracardiac puncture at 25 weeks of age. db/db mice are homozygous for a spontaneous mutation of the leptin receptor (Leprdb) leading to unrestrained weight gain and eventual development of obesity-associated diabetes. db/db but not db/+ mice exhibit hyperglycemia as early as 8 weeks of age and have been used to model human T2D (db/+) and 769 ± 41 mg/dl (db/db) (uman T2D . Althoug (db/db) .Statistical Analyses: The data are reported as means ± standard error of the mean (SEM), with statistical significance  determined by non-parametric analysis t-test unless otherwise stated. The kinetic parameters of Na+/Mg2+ exchange activation were analyzed with GraphPad Prism version 8.0.0 for Windows . Pearson and Spearman coefficients of correlation were estimated using SPSS 10.0 software .2+ homeostasis. To investigate the relationship between glycemic status and red cell Mg2+ homeostasis, we examined the correlation between HbA1c and erythrocyte Mg2+ levels in normal red cells. We observed a negative correlation between baseline levels of total cellular Mg2+ content and HbA1C levels  (2+ loss from RBC.We hypothesized that RBC membrane protein glycation (or another consequence of chronic hyperglycemia) may alter Mg n = 23) . These r2+ transport across the plasma membrane is mediated by Na+-dependent and Na+-independent mechanisms. We and others have shown that Na+-dependent Mg2+ efflux (Na+/Mg2+ exchange activity) contributes to RBC Mg2+ homeostasis  . These data suggest that reduced Mg content of RBC in hyperglycemic individuals reflects, at least in part, modulation of Na+/Mg2+ exchange activity.Cellular Mgeostasis . In this n = 23) . These r2+ regulation by high glycemic status, we assayed Na+/Mg2+ exchange activity as a function of extracellular glucose concentration from 0 to 100 mM, as described in Methods. RBC exposure to up to 100 mM glucose for 24 h at 37°C is known not to increase hemolysis, eryptosis, or concentrations of HbA1C or intracellular Ca2+ (2+-loaded RBC exhibited a glucose concentration-dependent increase in Na+/Mg2+ exchange activity (max) of 0.978 ± 0.01 mmol/1013 cell × h and EC50 of 18.1 ± 3.0 mM, representing a ∼50% increase over basal exchange activity in the presence of 100 mM glucose. In contrast, Na+-independent Mg2+ efflux was unaffected by changing extracellular glucose concentration . These results show that exposure of erythrocytes to high glucose media will modify cellular Mg2+ homeostasis.To study the mechanisms involved in RBC Mglar Ca2+ . We obseactivity . Kinetic+/Mg2+ exchange, we monitored time-dependent changes in exchange activity. RBC stimulated by 50 mM D-glucose were examined for Na+/Mg2+ exchange activity at 0.5, 1.5, 4, 12, and 24 h. Significant change in Na+/Mg2+ exchange activity was detected after 1.5 h, with peak response observed as early as 4 h . Thus, high glucose stimulates Na+/Mg2+ exchange activity in both Mg2+-loaded and -unloaded cells.To characterize the glucose-mediated activation of Nay as 4 h . We also2+ homeostasis. Protein glycation rate in RBC is time- and glucose concentration-dependent   as compared to cells incubated with 6 mM glucose . In contrast, incubation of cells with 50 mM sorbitol failed to alter RBC Mg levels . These observations suggest that the possibility that increased RBC surface glycation might stimulate Na+/Mg2+ exchange.We hypothesized that altering the glycation state of RBC surface proteins may change intracellular Mgependent . At highependent . To examsorbitol , and com < 0.05) . These r+/Mg2+ exchange  or mean corpuscular hemoglobin concentration (MCHC). However, total cellular Mg2+ levels were significantly lower in RBC from T2D subjects than in those from control subjects  than in RBC from normal subjects   did not differ statistically from that of normal RBC . These data are consistent with a major role for Na+/Mg2+ exchange in Mg2+ loss from T2D RBC. Furthermore, exposure to quinidine (500 μM) decreased Na+/Mg2+ exchange activity in RBC from T2D subjects by 0.44 ± 0.06 FU (n = 3) but only by 0.18 ± 0.07 FU (n = 4) in normal RBC (data not shown).We measured Na 0.0011) . In cont2+ levels and exchanger activity in ex vivo RBC from db/db mice, a well-described model of T2D, and in RBC from non-diabetic db/+ mice (db/db mice exhibited lower cellular Mg2+ content (2.3 ± 0.2 mmol/kg Hb) than RBC of db/+ control mice of similar age . db/db diabetic mouse RBC also exhibited higher rates of Na+/Mg2+ exchange activity than did RBC of nondiabetic db/+ mice  , and known “off-target” effects of SU6656  was higher than in cells from subjects with normal hemoglobin A expression (HbAA)  (+) was best fit by a hyperbolic Michaelis-Menten curve (r = 0.995) exhibiting a Km of 28.9 ± 2.4 mM for external Na+ and a Vmax of 1.16 ± 0.05 FU . In contrast, the Na+ -dependence of Na+/Mg2+ exchange activity in normal RBC was best fit by a sigmoidal curve  with an affinity constant for external Na+ of 83.5 ± 4 mM (p < 0.0001 vs. T2D) and a Vmax of 0.472 ± 0.01 FU, (p < 0.0001 vs. T2D), with Hill coefficient (n) of 6.4 ± 0.13. These results suggest that increased Na+/Mg2+ exchanger activity in T2D subjects may reflect increased affinity at extracellular Na+ binding sites possibly attributable to chronic exposure to high glucose.We previously reported that Vn (HbAA)  due in par (Na+) . In T2D 2+ was also examined  and T2D subjects (r = 0.996). RBC from normal subjects exhibited an affinity constant for intracellular Mg2+ of 5.97 ± 0.2 mM with Hill coefficient of 5.1 ± 0.1, as compared to an affinity constant of 7.87 ± 0.39 mM (n.s.) with Hill coefficient of 6.3 ± 0.2 in T2D red cells (both n = 3). Vmax in RBC from T2D subjects was 0.81 ± 0.032 FU vs. 0.50 ± 0.02 FU in RBC from normal subjects (p = 0.003). Since the affinity constants for intracellular Mg2+ were statistically indistinguishable in T2D and normal RBC, we propose that changes in external Na+ binding affinity and Vmax drive increased Na+/Mg2+ exchange activity in T2D RBC.The affinity for intracellular Mgexamined . Cells wexamined . Increas+/Mg2+ exchange activity, we incubated intact RBC with peptidyl-N-Glycosidase F (PNGase F) to remove accessible N-linked glycans from RBC surface proteins  TRPM6 and the thiazide receptor NCC of kidney  in vascular tissues . The time- and concentration-dependence of Na+/Mg2+ exchange activation by extracellular glucose, is consistent with those previously reported by Watala et al. for red cell membrane glycation (2+ uptake and homeostasis characterizes the streptozotocin-induced rat model of type 1 diabetes (T1D)  . Hepaticted rats . These d+/Mg2+ exchange activity to normal levels, reversing its elevation by high glucose levels. PNGase F exposure at 37°C for 1 h has been used to partially remove surface N-linked glycans from intact T regulatory cells without compromising cellular function  for extracellular PNGase regulation of erythroid Na+/Mg2+ exchange remain to be defined.We found that RBC pre-treatment with extracellular PNGase F restores Nafunction . We show+/Mg2+ exchange protein or of one or more interacting regulatory protein(s) can regulate intracellular Mg2+ and Mg2+ homeostasis in T2D RBC. Additional work is needed to identify the glycated and glycosylated proteins responsible for Na+/Mg2+ exchange activation in RBC of T2D subjects. Also remaining to be investigated is the possible effect on Na+/Mg2+ exchange of the recently reported deposition of amylin aggregates in or on T2D red cells (2+ transport may have parallels in endothelial and vascular smooth muscle cells, we speculate that identification and modulation of Mg-regulatory glycation and N-deglycosylation targets may have therapeutic potential in treatment of the vascular complications of T2D.Enhanced glycation of RBC and endothelial surface proteins can enhance vascular dysfunction, suggesting that attenuation of protein glycation might delay development of vascular complications in T2D. Our results suggest that RBC surface glycation and N-glycan state of the Naed cells . As regu


As the complexity of emergency care increases, current research methods to improve care are often unable to capture all aspects of everyday clinical practice. Video recordings can visualize clinical care in an objective way. They can be used as a tool to assess care and to reflect on care with the caregivers themselves. Although the use of video recordings to reflect on medical interventions (video-reflection) has increased over the years, it is still not used on a regular basis. However, video-reflection proved to be of educational value and can improve teams’ management and performance. It has a positive effect on guideline adherence, documentation, clinical care and teamwork. Recordings can also be used for video-reflexivity. Here, caregivers review recordings together to reflect on their everyday practice from new perspectives with regard to context and conduct in general. Although video-reflection in emergency care has proven to be valuable, certain preconditions have to be met and obstacles need to be overcome. These include gaining trust of the caregivers, having a proper consent-procedure, maintaining confidentiality and adequate use of technical equipment. To implement the lessons learned from video-reflection in a sustainable way and to continuously improve care, it should be integrated in regular simulation training or education. This narrative review will describe the development of video recording in emergency care and how video-reflection can improve patient care and safety in new ways. On our own department, the NICU at the LUMC, video-reflection has already been implemented and we want to further expand this. We will describe the use of video-reflection in our own unit. Based on the results of this narrative review we will propose options for future research to increase the value of video-reflection. Video recordings offer the possibility to visualize clinical care in a comprehensive and objective way. Due to the emergent nature of critical care, recordings proved to be a valuable addition in evaluation and improvement , 2. The EMBASE.com and Emcare (via Ovid) from inception to October 7th, 2021. Search terms included controlled terms (MeSH in PubMed and Emtree in Embase/Emcare) as well as free text terms. Search terms expressing ‘video’ were used in combination with search terms comprising ‘clinical audit.’ The primary researcher (VH) conducted a screening and made a list of articles that would be full-text assessed. This included all articles on different methods of video-reflection in emergency care. The literature was supplemented with studies found by reviewing the references of the included studies. A search strategy can be found in the This narrative review is based on a literature search which was performed in collaboration with a medical information specialist. To identify all relevant publications about video-reflection or audits of interventions in healthcare we performed searches in the bibliographic databases PubMed, Video recordings can help compare work-as-done with work-as-imagined. Work-as-done is a term describing the daily activities of everyday clinical work. Healthcare workers adapt and adjust their actions according to the specific situations they face and the needs of the patients they are caring for. Work-as-imagined describes the manner in which it is assumed that people will do their work. It refers to the way people who make guidelines or regulations believe the work should be carried out. There may be a considerable difference between what people are expected to do and what they actually do . RecordiAs a result of this, protocols can also be expanded or adjusted. Taylor et al. used video recordings to create specific time goals for key steps in trauma resuscitation to reduce the total amount of time spent in the trauma bay. Plan-Do-Study-Act cycles were used to define time goals in order to improve quality . Aydon eGuidelines focus mainly on technical aspects of care. However, it is also important to include non-technical aspects for a good quality of care. Studies show non-technical aspects, like communication, leadership and teamwork, can be assessed well with video recordings , 16–19. Video recordings can also be used to allow caregivers to reflect on their practice and evaluate the care given. This so called video-reflection enables caregivers to see what actually happened during a procedure and compares this with their recollection of what happened. Videotaping care has the benefit that it allows for assessment at any hour, without intrusion of an observer . The camMultiple studies have been carried out which try to improve quality of care by using recordings for video-reflection with the caregivers. Scherer et al.  showed tIn neonatal care, Root et al. studied a cohort of infants born before and after implementation of weekly video reflection and compared the recordings to the resuscitation guidelines. Providers complied more often to guidelines and correct documentation increased from 39 to 65% in the period after implementing weekly video-reflection sessions . Video-rHowever, the catch with video-reflection is how to actually use the findings for education or improvement in a way that is effective and sustainable. It is recommended for future team trainings to implement the findings of video reflection in a feedback system and to follow the changes that occur over time . Data acWhile recordings can be used to focus an individual on their errors or non-compliance, there is also a different approach. Reflexivity uses recordings to enable caregivers to review recordings together to learn from interventions, context and conducts and collaboratively find ways to improve care , 34. WheHor et al. used reflexivity to design the space in an intensive care unit to maximize communication effectiveness. In the IC ward an open-plan design was used for accessibility. However, the open space gives more opportunities for interruptions as well. This study showed how video-reflexivity can be used to establish improvement as an ongoing process instead of a response to adverse events. They used solutions such as changes in behavior and reflection to improve communication . ReflexiIn summary, video-reflexivity can be used to visualize care and social structures in new ways to drive continuous change and improvements. Especially in emergency care the environment can be chaotic. Through reflexivity caregivers can get a full overview of all the different aspects of emergent care and give input on improving the quality of care.Even though we live in a social media era where recording is part of everyday life, recording care is not yet a general practice , 42. CarTo activate the caregivers, Lloyd et al. recommends to generate short-term wins to create a sense of urgency. For example, when the implementation of a new checklist has improved verbal skills of the team leaders during intubation, this should be visible for the entire organization and celebrated . Dumas eStill, common hurdles of video review that remain within a team are technical challenges like functioning of equipment and storing of videos. Other challenges are time and resource constraints, as it is time consuming to prepare video-reflection sessions and storage capacity needs to be considered carefully before the start of a video-reflection project , 49. TheCultural differences may also play a role in implementing video-reflection, but so far no studies have analyzed this. However, studies have shown that ethical and legal issues play a role , 45, 50.When comparing a camera to an observer who is present to assess care, the observer present can be biased or miss certain aspects because they need to take it all in at once. Observers watching a recording however, can assess communication and leadership independently from technical quality . HoweverAs a solution, recordings can be made more all-encompassing by adding vital parameters that are monitored to the recordings. In neonatal resuscitation, a Respiratory Function Monitor (RFM) has been used to provide information on the physiological parameters of infants . Van VonAnother method to make recordings more comprehensive is to add recordings of eye-tracking glasses. These give a unique point of view, e.g., the healthcare providers’ gaze. Wagner et al. showed that it is feasible, comfortable and has educational benefits. It can even be used for live time streaming to observers that are not present in the same room . Larsen Technology continues to develop and recordings are made more all-encompassing by adding vital parameters of the patient. This helps to understand complex care and team challenges. In trauma care, a so called Trauma Black Box has been developed. A black box from aviation contains a Flight Data Recorder where dozens of measurements from the airplane are stored combined with voice recordings from the cockpit. In emergency care, combined recordings of sound, video and vital parameters can also create a ‘flight recorder,’ e.g., it showcases a detailed recollection of what exactly went down during an intervention. This novel technology can be used to drive change and improve patient safety in the future . A diffeVideo and physiological parameter recording of neonatal stabilization was implemented at the Neonatal Intensive Care Unit (NICU) of the Leiden University Medical Center (LUMC) in 2009. Since 2014 weekly and plenary review sessions are held where recordings of neonatal stabilization are reviewed, focused on mostly on technical aspects . RecordiOur department want to continue using video recordings to improve patient care and safety in new ways. Using the insights from this review, we propose a set-up for a future study on the implementation of video-reflection and using it to improve quality of care . The focVideo recording in emergency care has developed in many ways in the past years. It has been used as a tool for research and gives an objective view on work-as-done. Also, it has been used to improve care by showing recordings to the caregivers themselves which enables reflection and reflexivity on their actions. Still, it remains unclear how video-reflection can be best used to improve care or integrated in education to drive change. Although reviewing recordings in emergency care has been studied, this is mostly on the effect on guideline adherence or clinical skills. The improvement for long term and short term outcomes for the patient and the caregiver are still subject of research. Therefore, we suggest future studies should focus on how video-reflection is best implemented and used to improve quality of care.VHee and RW drafted the initial version of the manuscript. All authors participated in critical revision of the manuscript for important intellectual content, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.


Evacuees of the Great East Japan Earthquake have experienced adverse, long-term physical and psychological effects, including problem drinking. This study examined the risk and recovery factors for problem drinking among evacuees between fiscal years (FY) 2012 and 2017 using data on residents in the evacuation area from the Mental Health and Lifestyle Survey. With the FY 2012 survey as a baseline, a survey comprising 15,976 men and women was conducted in the evacuation area from FY 2013 to FY 2017, examining the risk and protective factors for problem drinking. Particularly, the Cutting down, Annoyed by criticism, Guilty feeling, and Eye-opener (CAGE) questionnaire was used to evaluate problem drinking. Univariate and multivariate Cox proportional hazard models were constructed to identify the risk and recovery factors of problem drinking. The findings indicated that the male gender, insufficient sleep, job change, trauma symptoms, mental illness, family financial issues, and heavy drinking (≥4 drinks per day) were significant risk factors for the incidence of problem drinking among the evacuees. Furthermore, a high blood pressure diagnosis could exacerbate problem drinking among men, while younger age and a diabetes mellitus diagnosis could increase problem drinking among women. Trauma symptoms and heavy drinking inhibited recovery from problem drinking after the disaster. Understanding these factors can shape effective long-term intervention strategies to physically and psychologically support evacuees. Research has shown that post-traumatic stress after natural disasters is linked to an elevated risk of problem drinking  and subsBased on these research findings, the present study examined the risk and protective factors for problem drinking within the context of the Great East Japan Earthquake and Tsunami of 11 March 2011 ,13. ThisThis study used data from the Mental Health and Lifestyle Survey that assessed the mental health and lifestyle of residents of evacuation areas after the Great East Japan Earthquake. The complete survey protocol was published in FY 2012 . The tarn = 184,507). The sample population excluded those who did not answer the CAGE questionnaire in FY 2012 (n = 9899) and who did not respond to the questionnaire independently (n = 2547), because CAGE can only be assessed through self-response. Furthermore, respondents with a CAGE score of ≥2 (n = 3241) in FY 2012 were excluded. The remaining 27,064 respondents  formed the baseline sample for follow-up. Likewise, those individuals who did not respond on their own to the assessment from FY 2013 to FY 2017 (n = 620), and did not respond to the follow-up , were excluded. Thereafter, the longitudinal data were obtained for 15,976 participants .n = 27,064) in FY 2012. The remaining 3241 respondents  formed the baseline sample for follow-up. Similarly, individuals who did not respond to the questionnaire independently from FY 2013 and FY 2017 (n = 61), or who did not respond to the follow-up (n = 373) were excluded from the sample. Thereafter, longitudinal data were obtained from 2807 participants .This study evaluated all variables used previously ,13, inclTo align with previous studies ,13, heavThe CAGE questionnaire is used to screen for alcohol dependency  and diagThis study evaluated various demographic characteristics, socio-economic factors, and disaster-related risk factors related to problem drinking ,20,21. DThe Lubben Social Network Scale (LSN-6) was used to screen current social networks, including family and friends, among the evacuees ,23. The Research has shown that individuals face sleep problems after traumatic events . An earlThis study used the six-item Kessler Psychological Distress Scale (K6) to screen for non-specific serious mental illnesses , in whicComorbidity of PTSD and problem drinking has been well-documented ,28. TherThis study analyzed data for six years, from FY 2012 to FY 2017, using univariate Cox proportional models to investigate possible predictors of problem drinking. The analysis used FY 2012 as the baseline and FY 2013 to FY 2017 as the follow-up period. For participants who had multiple visits during the follow-up, the most recent data were used in the analysis as the follow-up results. The dependent variables were chosen based on previous studies [p < 0.05 indicated statistical significance.All statistical analyses were performed using SAS 9.4 . Univariate and multivariate Cox proportional hazards models were used to obtain crude and adjusted hazards ratios (HRs) and 95% confidence intervals (Cis) for the association between each factor and problem drinking or recovery. Multivariate Cox proportional hazards models for men and women were established to determine differences based on gender. p < 0.05).p < 0.05).This study also examined the factors that enabled recovery from problem drinking between FY 2012 and 2017. This study examined the risk and recovery factors for problem drinking from FY 2012 to FY 2017 among evacuees from regions affected by the Great East Japan Earthquake. The results showed that there are some similarities and differences between men and women in developing problem drinking after disasters. Additionally, heavy drinking (≥4 drinks) and trauma symptoms (PCL ≥ 44) were found to be significant factors that prevented recovery from problem drinking among both genders. Previous studies have reported that individuals are impacted by drinking behavior, including alcohol consumption for two years after traumatic events ,32,33,34This research found that a substantial proportion of the sample (15.5%) developed problem drinking within six years of experiencing a compound disaster. This implies that several evacuees still suffered from disaster-related drinking problems for more than a few years after the disaster. Therefore, one must provide seamless support for evacuees who suffer from drinking issues by understanding any risk factors such as trauma issues and any other risk factors underlying problem drinking. The results also show that alcohol consumption (≥4 drinks), disaster-related factors, family finances, and sleep insufficiencies were related to the development of problem drinking from FY 2012 to FY 2017, which were the same risk factors in the chronic post-disaster phase from FY 2012 to FY 2013. Additionally, heavy drinking was found to be a significant factor in the development of problem drinking from FY 2012 to FY 2017 among men and women. Risk factors for the development of problem drinking in the chronic phase after a compound disaster, such as male sex, sleep insufficiency, trauma symptoms (PCL-S ≥ 44), and family finances, were constant from FY 2012 to FY 2013. Notably, upon comparing the HR in the short-term research from FY 2012 to FY 2013, the HR of men with problem drinking in the present study from FY 2012 to FY 2017 (2.03 95% CI: 1.83–2.04) was higher than the odds ratio  in the previous study [Variation based on gender was found in the risk factors for developing problem drinking from FY 2012 to FY 2017. Sleep insufficiency and high blood pressure were significant risk factors in men. Furthermore, women of a younger age  and diagnosed with diabetes mellitus and mental illness constituted significant risk factors. An association between physical illnesses such as high blood pressure and diabetes mellitus and the development of problem drinking among evacuees is a new finding. Moreover, insomnia has been strongly associated with problem drinking ,36 as alp < 0.05). The results may indicate that women who were diagnosed with diabetes mellitus with problem drinking had a high tendency of having felt that they ought to cut down on their drinking and felt guilty of their drinking behavior. A study previously reported that evacuees experienced difficulty in accessing medication, treatment, and clinical services [Assessing the differences in risk factors based on gender is crucial for understanding how problem drinking develops and when particular intervention plans can be implemented. In contrast to the preceding short-term study between FY 2012 and FY 2013, this study found differences based on gender. A history of diabetes mellitus and mental illness was significantly associated with the risk of problem drinking among women. To examine whether the result is a reversal of causality, the results of the follow-up study, excluding the FY 2013 data, were analyzed, as shown in the services . ParticuThus, this study analyzed factors that prevented the development of problem drinking from FY 2012 to FY 2017 for both genders. Unfortunately, the current results did not reveal any specific protective factor. However, it was found that trauma symptoms and alcohol consumption prevented recovery.Therefore, the LSN-6 may be a key protective factor for evacuees with problem drinking. Research has also presented disaster research on the Great East Japan Earthquake, suggesting that continuous intervention for evacuees with alcoholism who lived alone in temporary housing helped them recover from their drinking problems . Thus, iBased on current knowledge, this is the first study to examine risk and protective factors for problem drinking among evacuees affected by the Great East Japan Earthquake between FY 2012 and FY 2017. Particularly, this study compared the risk factors for problem drinking between the period from FY 2012 to FY 2013 and FY 2012 to FY 2017 among men and women. Consequently, problem drinking was found to be caused by physical, psychological, and economic crises, and risk factors increased substantially between FY 2012 and FY 2017. This suggests that medical practitioners should implement long-term interventions to support evacuees with problem drinking habits.Meta-analyses and population-based studies have demonstrated how alcohol consumption changes after a traumatic event and/or with risk factors ,39. HoweThis study has several limitations. First, the response rate was 19.9% in FY 2012. Therefore, the results may have overestimated or underestimated the impact of problem drinking after the Great East Japan Earthquake. Second, a previous study explained that the persistence of feelings such as helplessness and hopelessness due to grief among evacuees was a predictor of increased drinking . HoweverThis study found that recovery from heavy alcohol consumption and alleviation of trauma symptoms are key factors in enabling recovery from problem drinking among evacuees. It contributes to the literature by identifying risk and protective factors for problem drinking in the long term. Understanding these factors can shape effective long-term intervention strategies to physically and psychologically support evacuees. The practitioners are required to continue to have long-term, large-scale surveys, to conduct follow-up interventions for the evacuees who have suffered from a drinking problem.Therefore, the government needs funding to provide long-term support for evacuees recovering from alcohol addiction.


Excessive alcohol consumption, as part of an unhealthy lifestyle, can contribute to metabolic abnormalities. This study investigated the sex differences in the relationship between excessive drinking and the risk of metabolic abnormalities. This community-based study included 3387 participants  from the northeastern region of Taiwan. All participants completed a demographic survey and were subjected to blood tests. The risks of excessive drinking were evaluated using the Alcohol Use Disorder Identification Test (AUDIT). The results showed that males were at higher risks of obesity, hypertension, and hypertriglyceridemia, but at a lower risk of abdominal obesity than females. Males with hazardous drinking were at greater risks of hypertension, hyperglycemia, low serum levels of high-density lipoprotein cholesterol, and hypertriglyceridemia compared to those with no drinking. Females with hazardous drinking were at a greater risk of hypertension than those with no drinking. There was no interaction effect of sex and excessive drinking on the risks of metabolic abnormalities after controlling for demographics and lifestyle-related habits. Future studies are warranted to explore the sex-specific risk factors for metabolic abnormalities and to elucidate the mechanism underlying this association between alcohol consumption and metabolic abnormalities. Metabolic syndrome (MetS) refers to a collection of symptoms that increases the risk of insulin resistance along with abnormal adipose deposition and function ,2. The dExcessive alcohol consumption is toxic to almost every tissue of the body . PreviouMoreover, evidence suggests that the predictors of MetS are sex-specific. For example, females may be more vulnerable to developing MetS under work stress and with low socio-economic status . A previCompared to females, males are more prevalent to engage in problem drinking and develop alcohol use disorders . HoweverThis study investigated the relationship between alcohol consumption and metabolic abnormalities among the general population in Taiwan to fill the research gap. Furthermore, we explore whether sex is a modulating factor in such a relationship.The Institutional Review Board of the Chang Gung Memorial Hospital approved this research (IRB No: 103-3886C). All participants agreed to the study conditions and provided their informed consent before enrolling in this study.2) was calculated as weight (kg) divided by height (m) squared. Waist girth was measured at the midline between the lowest margin of the subcostal rib and the upper margin of the iliac crest.In total, 3387 participants  were enrolled. Participant recruitment and sample preservation were conducted at the Northeastern Taiwan Community Medicine Research Cohort . The inclusion criteria were age >30 years and absence of pregnancy. All participants completed a questionnaire survey that assessed their demographics  and lifestyle-related habits (including smoking and drinking behavior). Further, physical examination included measuring the heart rate, blood pressure, body weight, body height, and waist girth (circumference). Body mass index  . The AUDA race-specific waist girth threshold, based on the NCEP ATP III criteria ,34, was p < 0.05.Data were analyzed using the Statistical Package for the Social Sciences for Windows . Variables are presented as mean ± standard deviation or frequency. All statistical tests are two-tailed, and differences were considered significant at 2) or Fisher’s exact test to compare the categorical variables between participants with different risks of excessive drinking. Furthermore, we used the one-way analysis of variance to compare the continuous variables between groups. Subsequently, multivariate logistic regression was used to determine the effects of excessive drinking on metabolic abnormalities while controlling for age, education levels, marital status and smoking. The metabolic profiles (obesity and each criterion of MetS) were set as dependent variables . The risks of excessive drinking and age of the participants were set as independent variables. Finally, we examined the interaction effects of sex and excessive drinking on metabolic profiles by logistic regression, controlling for age, education levels, marital status and smoking.We used the Chi-square test  from the northeastern region of Taiwan. Among all participants, 1863 (55%) did not drink, 1217 (35.9%) were low-risk drinkers, and 307 (9.1%) had hazardous drinking. p < 0.001), hypertension , and hypertriglyceridemia , but at a lower risk of abdominal obesity  than females.Logistic regression, controlling for age, education levels, marital status and smoking revealed that males were at higher risks of obesity . The hazardous drinking group had the highest proportions of males (p < 0.001), smoking (p < 0.001) and betel nut use (p < 0.001), and had the highest BMI (p < 0.001) and levels of AST (p < 0.001), ALT (p < 0.001), bilirubin (p = 0.016), r-GT (p < 0.001), AFP (p = 0.001), HbA1c (p = 0.002), uric acid (p < 0.001) and the lowest levels of adiponectin (p < 0.001) and leptin (p < 0.001). In terms of metabolic abnormalities, those with hazardous drinking had higher risks of hypertension (p = 0.003) and hyperglycemia (p = 0.001), hypertriglyceridemia (p < 0.001), and MetS (p = 0.004) compared to those with no drinking.p = 0.003), hyperglycemia , low HDL-C , and hypertriglyceridemia  than those with no drinking. Males with low-risk drinking were at a greater risk of hyperglycemia  than those with no drinking. In females, those with low-risk drinking were at a greater risk of obesity  and hyperglycemia  than those with no drinking. Females with hazardous drinking were at a greater risk of hypertension  than those with no drinking. No interaction effect of sex and excessive drinking on the risks of metabolic abnormalities was observed after controlling for age, education levels, marital status and smoking.The large-scale sample in our study indicated that males were at higher risks of obesity, hypertension, and hypertriglyceridemia, but at a lower risk of abdominal obesity than females. Males with hazardous drinking were at greater risks of hypertension, hyperglycemia, low serum levels of high-density lipoprotein cholesterol, and hypertriglyceridemia compared to those with no drinking. Females with hazardous drinking were at a greater risk of hypertension than those with no drinking. There was no interaction effect of sex and excessive drinking on the risks of metabolic abnormalities after controlling for demographics and lifestyle-related habits.It was found that frequent alcohol consumption contributed to a higher prevalence of MetS and its medical consequences in China  and SpaiThe association between hyperglycemia and alcohol consumption is controversial. Our study revealed that males with hazardous drinking were at increased risk of hyperglycemia. A Swedish study demonstrated outcomes comparable with ours . High alOur results showed that males with hazardous drinking were at greater risks of hypertension, hyperglycemia, low se-rum levels of high-density lipoprotein cholesterol, and hypertriglyceridemia compared to those with no drinking. Females with hazardous drinking were at a greater risk of hypertension than those with no drinking. A study conducted in Malta reported that males are at higher risk of MetS, and MetS components are significant predictors along with alcohol habits . A KoreaThis study has several limitations. First, it is a cross-sectional study, and the causal relationship between metabolic abnormalities and alcohol consumption was not determined. A prospective study is warranted to clarify the relationships between metabolic abnormalities and alcohol consumption. Second, several important lifestyle factors, such as dietary habits, family history, physical activity and occupational could be associated with alcohol consumption and metabolic profiles ,49 were This community study based in Taiwan revealed that males were at higher risks of obesity, hypertension, and hypertriglyceridemia, but at a lower risk of abdominal obesity than females. Males with hazardous drinking were at greater risks of hypertension, hyperglycemia, low serum levels of high-density lipoprotein cholesterol, and hypertriglyceridemia compared to those with no drinking. Females with hazardous drinking were at a greater risk of hypertension than those with no drinking. There was no interaction effect of sex and excessive drinking on the risks of metabolic abnormalities after controlling for demographics and lifestyle-related habits. Future studies are warranted to explore the sex-specific risk factors for metabolic abnormalities and elucidate the mechanism underlying the association between alcohol consumption and metabolic abnormalities.


Recently, younger men in Korean society tend not to view drinking as a proud feature of men who work. The relationship between gender role attitudes and high-risk drinking is expected to change accordingly. An online survey was conducted in January–February 2022, and the frequency of drinking, the amount of drinking, and traditional gender role attitudes, such as “men should be independent and women should take care of the children”, were measured. Participants were 786 men aged between 19 and 69 years. When comparing men in their 20s and 30s with those in their 40s to 60s, the younger men reported drinking relatively high amounts of alcohol in one place, and older men had a relatively high frequency of drinking. High-risk drinking was significantly higher in the older group. Gender role attitudes were more traditional in the older group and were a predictor of high-risk drinking in older men, but there was no significant relationship between the two variables in the younger age group. The results indicate that different generations have different perceptions of how men should drink. In addition to more detailed qualitative research on drinking motivation by generation, research on whether similar changes are occurring in other countries is needed. Problem drinking, drug abuse, smoking, overeating, and reckless driving are cited as representative health risk behaviors . HoweverIn Korea, drinking is a health risk behavior that needs to be managed more carefully. According to the National Health Statistics of the Ministry of Health and Welfare of Korea, as of 2020, the standardized high-risk drinking rate was 21.6% among Korean men  . BetweenRegarding the higher drinking tendency in men compared with women, from a biological perspective, Walther et al.  noted geHowever, as masculinity is recognized differently due to generational changes in Korean society, the attitudes of men toward drinking are also changing ,17. For The change in the masculinity of young men in Korea, called “Lee Dae-Nam 20s Male)”, is the result of a decrease in the possibility of achieving social status due to the widening gap between the rich and the poor, a change in the workplace culture due to labor flexibility and frequent turnover, and the emergence of masculinity in consumption ,20,21,22s Male”, One way to confirm the assumption that the Korean younger generation no longer associates drinking with the traditional values of masculinity is to examine whether young men’s gender role attitudes are likely to lead to drinking. Gender role attitudes refer to an individual’s perception of whether a traditional gender role is positive or negative. The more traditional the gender role attitudes in men, the more they perceive the roles of men and women to be different, and more “masculine”  behavior is affirmed . If thesTwo major previous studies have examined the relationship between male gender role attitudes and drinking in Korea. Chung  examinedThis study aimed to examine men’s drinking patterns in relation to age, gender role attitudes, and drinking behaviors. Based on previous empirical research, two hypotheses were examined. First, we hypothesized that drinking patterns would differ between the younger and older generations. Second, we hypothesized that traditional gender role attitudes would predict high-risk drinking; however, the size of the effect would differ by age.A separate survey was conducted for this study. The survey was named the “Gender Roles and Health Survey”. The main survey was conducted online from 24 to 26 January 2022. Additional investigations were conducted online for three days from 8 to 10 February 2022 by company Macromill Embrain . Notably, during the survey period, the COVID-19 quarantine policy was eased in Korea. Specifically, except for wearing masks, patterns of public life reverted to those before the pandemic. However, it is likely that the psychological and social impact of the COVID-19 pandemic influenced participants’ drinking behavior. This may be reflected in their reports of drinking frequency and average amount of alcohol consumed in the past year. Therefore, caution is required when interpreting the results of this survey or comparing them with findings from before or after the height of the COVID-19 pandemic.The study participants were directly recruited using an online panel owned by the research company, and the target population was adults between the ages of 19 and 69 across the country. To extract the sample, a random stratified sampling method was used considering the area of residence and age. Age was arranged to include a similar number by generation; in the case of gender, the number of participants was intentionally designated because it was a major variable in this study.n = 318, 40.5%) and 40s to 60s , in consideration of the characteristics of masculinity in Korea. Of those in their 20s–30s, 24.5% were married or living with a partner, and 80.6% of the men in their 40s–60s were married or living with a partner. In terms of the monthly average household income, 10.4% of the participants were classified as low-income (around KRW2 million), 69.5% as middle-income (KRW201–207 million), and 20.1% as high-income (KRW701 million or more). The participants’ level of education was 19.2% high school graduates, 67.1% college and university graduates, and 13.7% with graduate school or higher. During the data cleaning process, insincere response patterns or excessive outliers were not found; therefore, the quality of the survey was judged to be good overall. Additional weights were not applied during the analysis.In total, 1331 participants (897 men and 434 women) were recruited, and the analysis was limited to annual drinkers who had had at least one drinking experience in 2021. Of these, 786 (87.6%) men were selected as participants. The average age of the participants was 43.98 years (SD = 13.50). The age group was largely divided into those in their 20s and 30s ?” and was divided into five categories: less than once a month, about once a month, about 2–3 times a month, 2–3 times a week, and 4 or more times a week. The amount of drinking was arranged in units of standard glasses by asking, “How much alcohol did you usually drink in one place (in the past year)?”High-risk drinking variables were constructed using the Korean Disease Control and Prevention Agency (KCDC) standards . The KCDGender role attitude (GRA) scales are used worldwide, especially in comparisons between countries, to measure an individual’s gender role values . The GRAIn this study, the tool of Vermeersch et al. for measuring gender role attitudes  was usedAn exploratory factor analysis was performed on the measured data to determine whether the use of the gender role attitudes scale was appropriate. During orthogonal rotation, the varimax method was adopted, and factor analysis was performed using the principal axis decomposition method. The sample adequacy measurements and Bartlett’s sphericity verification results before the exploratory factor analysis were all good, and the MSA value was 0.860 or higher, showing no abnormalities. Two factors could be distinguished according to the Kaiser criterion, which determines whether a factor with an eigenvalue of 1 or more is a meaningful separate factor. As a result of verifying the internal fit of all 11 items, good values were also obtained (Cronbach’s α = 0.876). Accordingly, the 11 items were composed of a single dimension, in line with the results of the original study that developed the tool.In many studies on drinking norms, injunctive and descriptive norms are used interchangeably . When inTo confirm the injunctive and descriptive norms of drinking, one of the normative items that showed the greatest influence on drinking behavior was selected in a study related to drinking norms in Koreans ,41.Injunctive drinking norms were measured based on tolerance of drinking. Participants were asked “What do you think about drinking and getting drunk?” Reponses were rated on a 5-point scale ranging from “not okay at all” to “very good.” Descriptive drinking norms gauged friends’ drinking behavior, asking “How often do you think your friends drink alcohol?” Six categories were selected: never drank, less than once a month, once a month, 2–4 times a month, 2–3 times a week, and 4 or more times a week.Age, education level, marital status, household income, and smoking status were selected as sociodemographic variables. Age was classified as international age, and education level was classified as lower than high school graduate, junior college graduate, college graduate, or higher than graduate school. For the classification of marital status, married and cohabiting were combined, and the rest were separated. Household income was divided into eight categories: none, ~KRW2 million, KRW2.01–3 million, KRW3.01–4 million, KRW4.01–5 million, KRW5.01–6 million, KRW6.01–7 million, and more than KRW7.01 million. Smoking was classified into three categories: no smoking at all, quit smoking in the past, and smoking.In this study, a binary logistic regression analysis was performed because the dependent variables had values of 0 and 1. Before the logistic regression, relationships within gender role attitudes variables were identified using correlation analysis. All analyses were performed using IBM SPSS 20.t-test, the frequency of drinking was significantly higher in the older age group, while the average amount drunk was higher in the lower age group at the 95% confidence level.The high-risk drinking rate was 24.5% in participants in their 20s and 30s, and 38.0% in those in their 40s to 60s, a difference of 13.5%. The chi-square test indicated the difference was significant at a confidence level of 99.9%.younger = 2.33, Molder = 3.11) and 5 , the differences between the generations are remarkable. In both age groups, the strongest endorsement was for Item 1 , referring to “A boy behaving like a girl is disturbing” and the lowest was for Item 8 , referring to whether a woman performing a typically masculine job was unfeminine. When the average of all questions was calculated to create a total score, the gender role attitudes score for those in their 20s and 30s was 2.47 (SD = 0.77), and that for those in their 40s to 60s was 2.90 (SD = 0.61). The difference was 0.43 points higher for the older generation, and this difference was significant at a confidence level of 99.9%.Close relationships were found among the items. Considering this result, the results of the previous exploratory factor analysis and the evaluation of internal consistency reliability, the gender role attitudes scale was considered to be a unidimensional scale that assesses traditional attitudes about gender roles. Higher scores indicate more traditional attitudes.Logistic regression analysis of the factors influencing high-risk drinking according to age group revealed significant differences in age, education level, and gender role attitudes . For thoThis study examined whether gender role attitudes could have a significant effect on high-risk drinking among Korean men when various demographic variables and drinking norms were controlled for. In the process, the generations were divided into two age groups: those in their 20s and 30s, and those in their 40s to 60s. More attention was paid to the difference in the influence of gender role attitudes. While the results indicated that Korean men in the older age group drank more frequently, the average amount of alcohol consumed in one place was higher in the younger age group. Among annual drinkers, high-risk drinkers accounted for 38% of men in their 40s to 60s, 13.5% more than 24.5% of men in their 20s and 30s. Therefore, high-risk drinking in the older age group was more closely related to the frequency of drinking than to the amount of alcohol consumed on each occasion of drinking.In this study, consistent with Chung et al. (2012) and Windle et al. (2008), an inverted U-shaped curve trend of high-risk drinking according to age was found ,42. In tEducation level was found to be a predictor of high-risk drinking in the older group (95% OR = 0.522–0.857) but not in the younger generation. As summarized by Huerta and Borgonovi , contradWhen examining gender role attitudes, the older group had higher mean scores than the younger group for all 11 measurement items and the total score at a 95% confidence level. Item 1 (“I find it disturbing if a boy behaves like a girl”) had the highest score for both those in their 20s–30s and 40s–60s, and Item 8  had the lowest score. When ranking the items from the highest mean score to the lowest by age group, the younger age group’s rankings were Items 1, 5, 11, 4, 7, 9, 10, 2, 3, 6, and 8, and the older group’s rankings were Items 1, 5, 4, 3, 11, 2, 10, 6, 7, 9, and 8. Items 7 (“Only slim girls are attractive to boys”) and 9 (“A man should avoid being dependent on others”) were ranked more highly by the younger group than by the older group. The item with the highest ranking was Item 3 . Considering the items’ rankings, the relatively younger generation scored more traditionally regarding what the position of a woman should be, whereas the older generation showed a more traditional view of what a man position should be.Men’s traditional gender role attitudes were a predictor of high-risk drinking in the older age group, which is consistent with previous studies ,27,28,30Piotrowski et al.  showed aThis study has several limitations that deserve mentioning. First, although the reliability and validity of the developed gender role attitudes scale was verified, it has not been confirmed whether the reliability and validity were maintained even after being translated into Korean and used for all Korean males. Second, a standardized alcohol consumption questionnaire, such as the AUDIT-10, was not used. As the amount and frequency of drinking were self-reported, reports of drinking behavior can be arbitrary and recall bias may have affected responses to the items. Third, drinking norms were controlled as variables that could be correlated with both high-risk drinking and gender role attitudes, but other key drinking-related variables such as drinking motives were not sufficiently controlled for. Fourth, these data are cross-sectional, so it is not possible to determine causality. Fifth, men’s unique psychological problems, such as male-specific depression symptoms that can affect men’s drinking, were not controlled for.Another consideration is the close relationship between masculinity and drinking behavior, and that high-risk drinking itself may have the effect of reinforcing gender role attitudes; thus, attention should be paid to the interpretation of the relationships between the variables. Furthermore, the gender-dichotomous characteristic of the gender role attitudes scale itself remains, and it is regrettable that it did not explain the differences within men according to sexual and gender identity, such as gay, bisexual, or transgender men. Finally, although gender role attitudes were the focus of our study, it is important to also assess the extent to which gender role norms have changed over the past 70 years, and to assess the participants’ perceptions of such changes.This study confirmed that young Korean men in their 20s and 30s consumed more drinks than older men on each occasion of drinking, while older men in their 40s to 60s drank more frequently. In addition, in younger men, gender role attitudes were not a predictor of high-risk drinking, whereas in older men, the more traditional the gender role attitudes, the higher the probability of belonging to the high-risk drinking group. Of course, a change in gender role attitudes toward egalitarianism is welcome from both a gender equality perspective and a drinking risk perspective, but the expectation that these changes will reduce male drinking behavior may no longer be meaningful. Young men in Korea tend to drink in a way that is unrelated to their gender role attitudes. According to previous studies ,17 and t


As a part of China's efforts to mitigate and control air pollution in key areas, the Air Pollution Prevention and Control Action Plan was implemented in 2013, and several regulatory measures were introduced. Based on the data from 271 prefecture-level cities between 2008 and 2018, the difference-in-differences model is used to explore the effect of it on sulfur dioxide intensity in our study, and several significant results are as follows: (1) The baseline results suggest a 23% reduction in sulfur dioxide intensity in pilot cities compared to non-pilot cities. (2) The total factor productivity fails to play a partial mediating role in reducing the sulfur dioxide intensity under the implementation of the policy. (3) The results of the triple differences model suggest that the policy still exerts significant adverse effects on sulfur dioxide intensity in the pilot areas of the carbon emission trading scheme. Taking advantage of China's reform and openness, China has made remarkable economic progress and improved people's living conditions. However, it also leads to some problematic environmental issues. Air pollution, represented by sulfur dioxide pollution, is a serious problem that many developing countries, such as China, pay close attention to Arceo et al. . On the 10 concentration at the prefecture level and above cities will drop by more than 10% compared to 2012, and the number of days with air quality standards will increase year by year. PM2.5 concentrations in the Beijing-Tianjin Hebei region, the Yangtze River Delta, and the Pearl River Delta should fall by about 25, 20, and 15%, respectively  as the mediating variable in this paper. Last but not least, exploring the sulfur dioxide intensity reduction effect of the APPCAP policy can provide strong evidence for further expansion of this plan in China and benefit other developing countries seeking to reduce air pollution.The remainder of our paper is structured as follows: Section 2 presents the literature review, and the empirical strategy is described in Section 3. Section 4 shows the empirical results and a series of analyses. Section 5 draws conclusions and policy recommendations.2.5 concentrations, and its implementation has remarkably improved the total factor productivity of listed enterprises in pilot cities. Wang et al.  and propensity score matching difference-in-differences (PSM DID) methods, Yu et al.  is to be further significantly reduced.The third type of literature is the impact on human physical and mental health and disease risk after implementing the APPCAP policy. For example, Maji et al.  used aire et al.  combine  and Kim  use nati and Kim  found thIn summary, although the existing literature has done much affluent research on the implementation effect of the APPCAP policy from different perspectives, there is still a lack of analysis of the national distribution data of APPCAP pilot cities , as wellTaking China's APPCAP policy as a quasi-natural examination, we conduct a DID model to explore such policy's impact on sulfur dioxide intensity. As a magnificent tool for policy assessment, the DID estimation can principally avoid endogeneity problems. Explicitly, our DID estimation can contrast sulfur dioxide intensity in APPCAP cities (treatment group) and non-APPCAP cities (control group) in the pre-and post-implementation of the APPCAP policy, and the estimated equation is as follows.i denotes city, t indexes year, respectively. ISOit is the independent variable and refers to sulfur dioxide intensity. If city i implements the APPCAP policy, the value of Timei is 1, and 0 otherwise. Treati is the dummy variable. Treati =1 denotes the APPCAP policy has been implemented and Treati = 0 represents the APPCAP policy has not been implemented. Controlit is a series of control variables. The city fixed effects (μi), and the year fixed effects (θt) are also included in our equation. εit indicates the random error term.Where Time×Treat, α1, captures the net impact of China's APPCAP policy on sulfur dioxide intensity. Explicitly, a negative and significant indicates that the APPCAP policy effectively reduces sulfur dioxide intensity and approves the pollution-reduction effect of the APPCAP policy. Instead, a positive and significant indicates that the APPCAP policy aggravates sulfur dioxide intensity. Furthermore, the insignificant suggests that the APPCAP policy fails to influence pollutant emissions. In addition, Controlit implies the control variables selected in this study, including per capita GDP, industrial structure, industrialization level, population density, FDI, temperature, and rainfall.The coefficient of According to the method of Wen et al. , in ordeTFPitrepresents the total factor productivity. In addition to using the OLS estimation method, the Bootstrap test is also used to verify whether TFP played an intermediary role in the APPCAP policy's effect on sulfur dioxide intensity in our study. Among them, the Bootstrap method is a non-parametric estimation method. When the final Bootstrap confidence interval does not contain a value of 0, the mediating effect is significantly not equal to 0. Through the Bootstrap test, the robustness of the mediation effect can be further judged.Where β represents a constant and ω represents a coefficient Matrix, ρ represents the error term, and 1 is significant, step (2) is performed; otherwise, the test ends. In step (2), we test the coefficients ω2 and ω4, and when both are significant, the indirect effect is significant, and we go directly to step (4) for further testing. If at least one of the two is not significant, the test for step (3) will be performed. In step (3), we perform a bootstrap check. When the results are significant, indicating significant indirect effects and the procedure progresses to step (4); Otherwise, the mediating effect is insignificant, and the test stops. In step (4), we test the coefficient ω3; if the result is significant, it indicates that the direct effect is significant, and the process enters step (5); if it is not significant, then the direct effect is not significant, we only find an intermediate effect, and the effect is wholly mediated. In step (5), we compare whether ω2×ω4 and ω3 are the same, if they are the same, indicating a partial mediating effect, if different, indicating the presence of a masking effect. The above process can determine whether the APPCAP policy is associated with sulfur dioxide intensity by influencing the mediating variable, total factor productivity (TFP).The test step is as follows: In step (1), we test the total effect; if the coefficient ωSulfur dioxide emission and GDP are selected to measure the magnitude of sulfur dioxide intensity in our work, and we use sulfur dioxide emissions to GDP to express sulfur dioxide intensity. In particular, our empirical analysis below is dominated by Log (sulfur dioxide intensity) and supplemented by sulfur dioxide intensity.Time × Treat, our core explanatory variable, represents a proxy measure for the APPCAP policy shock. Specifically, if a city is an APPCAP city, then the key explanatory variable is 1 in the ongoing and subsequent years and 0 in all others. There are 47 cities in the “three districts and ten groups” that belong to the vital air pollution areas in APPCAP policy, such as Beijing–Tianjin–Hebei, Yangtze River Delta, Pearl River Delta, central Liaoning, Shandong, Wuhan, and its surrounding areas, Chang-Zhu-Tan, Chengdu, Chongqing, the economic zone on the west side of the straits, central and northern Shanxi, Shaanxi, Guanzhong, Ganning and Urumqi, accounting for 17.34% of all-city sample (271 cities) during sample period. These 47 cities are treated as the pilot cities , and the rest 224 cities are treated as the non-pilot cities . The mean values of the critical variables in the pilot and non-pilot cities are provided in Malmquist was first proposed by the Swedish economist Sten Malmquist in 1953 and has been widely recognized by the academic community. Therefore, this paper uses Malmquist to measure TFP, and its calculation formula is as follows:APPCAP has been implemented since 2013, and therefore, this study selects 2008–2018 as the regression period. The data of the explained and explanatory variables and control variables in our study are obtained from the “China City Statistical Yearbook,” “China Statistical Yearbook on the Environment from 2008 to 2018,” and “The local Statistical Yearbook.” The per capita GDP is deflated using the per capita GDP index based on 1978. Foreign direct investment (FDI) is initially converted using the exchange rate and then deflated using the fixed asset investment price index in 1990 as the base year. The descriptive statistics of the variables are listed in Time×Treat are significantly negative at the level of 1%, indicating that the APPCAP policy can reduce the sulfur dioxide intensity in pilot cities.Through the analysis of column (4) in 2, in line with the findings of Dong et al.  of g et al. . As presThe DID model requires no systematic differences in the trend of sulfur dioxide intensity before implementing the APPCAP policy, and even if there are differences, these differences are fixed. The horizontal axis in In order to solve systematic differences, we further combine propensity score matching with DID (PSM-DID). Namely, we cannot guarantee that APPCAP and non-APPCAP cities have similar characteristics before implementing the APPCAP policy. There may be a considerable variation in the 271 cities we have chosen as samples before, so we use the PSM-DID approach to mitigate systematically. To check whether omitted variables influence the DID estimates, we designed a placebo test by randomly assigning APPCAP status to cities so that we can figure out whether our findings are the result of APPCAP policy. Because 47 cities are treated as pilot cities, we decided to randomly select the same number of cities as the treatment group, constituting a pseudo-interaction term. Then, we perform the regression with the setting of Equation (1). Based on our assumptions, and the results should not be remarkable unless the random cities are the same as the actual cities. To make the results more convincing, we ran the random procedure 500 and 1000 times, respectively.p-value obtained from 500 and 1,000 simulations randomly assigning the APPCAP status to cities and the curve is the kernel density distribution of the estimation coefficient. Furthermore, the horizontal dashed line is a significance level of 0.1, and most of the estimates' p-value is more prominent than 0.1, implying that passing the great test is a small probability event. These observations suggest that unobserved factors do not drive the adverse and significant effects of APPCAP on sulfur dioxide intensity.To further eliminate the possibility of primary regression results being influenced by other factors, we conduct a robustness test on the DID model result by substituting the dependent variable because we consider that the impact of the APPCAP is not limited to sulfur dioxide intensity. Therefore, we choose carbon dioxide emissions and carbon intensity as the dependent variable. We can assume that the result is robust if the cross-term coefficients between the time and treat dummy variable are remarkable. The result in To further demonstrate that our results are robust, this study expands the DID model to a DDD model by introducing the dummy variable of the carbon emission trading scheme, and the areas covered by the carbon emission trading scheme include Chongqing, Beijing, Tianjin, Shanghai, Guangdong, and Hubei. The triple cross-term can be understood as a change in sulfur dioxide intensity of the pilot area after the implementation of the carbon emission trading scheme and the APPCAP simultaneously. The coefficient of triple cross-term can be understood as the net effect of APPCAP on sulfur dioxide intensity in pilot areas after taking into account initial differences in policy effect caused by various external factors, the influence of different explanatory variables, differences between pilot and non-pilot areas, and the implementation of carbon market construction policies. As we can see in Time × Treat and sulfur dioxide intensity. Therefore, our study takes an IV test as an additional robustness test by using the ventilation coefficient as an instrumental variable based on Hering and Poncet  to column (4) are significantly negative at the 1% level. Therefore, our results are still robust. To sum up, even considering the potential selection bias problem in pilot cities, APPCAP policy still contributes to reducing sulfur dioxide intensity, which highlights the robustness of the core finding of this study.The pilot areas differ in many ways, for instance, in the climate, human factors, economic conditions, and natural environment. Therefore, to test whether regional differences will lead to bias in the regression results, in other words, we need to figure out if the APPCAP policy affects the pilot areas in different conditions, so we perform a heterogeneity analysis. We further divide the 47 pilot cities into three dimensions for DID regression, respectively, and the three dimensions are east and mid-west, heating and non-heating, and coastal and inland. Finally, we can consider our conclusion of this study to be robust if the cross-term coefficient is remarkable. It is generally believed that implementing environmental regulatory policies is an effective tool for air pollution governance. To improve air quality, China has piloted the APPCAP policy since 2013. Evaluating the influence of the APPCAP policy on sulfur dioxide intensity is of great significance for environmental regulatory policy formulation and economic development in China and other developing countries. Based on a panel data covering 271 prefecture-level cities between 2008 and 2018, our paper isolates the effect of the APPCAP policy on sulfur dioxide intensity with the employment of DID method and PSM-DID approach. We draw several main findings: (1) The baseline results suggest a 23% reduction in sulfur dioxide intensity in APPCAP cities compared to non-APPCAP cities. (2) An IV test deals with potential endogeneity problems, corroborating the baseline results. (3) The results of the DDD model suggest that China's APPCAP still exerts significant adverse effects on sulfur dioxide intensity in the pilot areas of the carbon emission trading scheme. (4) Our mechanism analysis indicates that total factor productivity (TFP) fails to play a partial mediating role in reducing the sulfur dioxide intensity under the implementation of the APPCAP policy. (5) The APPCAP policy significantly adversely affects the sulfur dioxide intensity in the heterogeneous analysis.We derive three policy recommendations from our results. First, the Chinese government should further expand the scale of its APPCAP policy. Our main finding is that the APPCAP policy has a powerful sulfur dioxide intensity reduction effect. Further expansion of the APPCAP policy can improve air quality while ensuring rapid economic development. Moreover, non-APPCAP regions can learn from APPCAP regions' successful experiences. Because of the regional difference, the APPCAP policy should be formulated with sufficient consideration of local air pollution and economic development. It is vital to combine policies tailored to local conditions. In addition, if we properly combine the APPCAP policy with other local policies in different cities, it will likely have an excellent synergistic effect.2, NO2, CO, and O3, in order to achieve the vision of gradually upgrading air quality standards and catching up with national air quality standards as soon as possible. At the same time, the specific formulation of policy formulation should also depend on improving air quality and cannot be rigid, blind, and “one-size-fits-all.”Second, the government should further improve the APPCAP policy to cover as many air pollutants as possible and specify specific emission control targets, such as adding long-term specific emission control indicators for air pollutants such as SOThird, as a potential intermediary factor, total factor productivity is vital in reducing sulfur dioxide intensity under the APPCAP policy, while the effectiveness of it is poor in this study. Therefore, China's local government departments should pay more attention to the energy efficiency of enterprises and how to improve the energy efficiency of enterprises in the first place, which not only has a positive impact on air governance but also helps to improve the level of local economic development. In addition, government departments should establish the concept of green development and innovative development, increase investment in R&D subsidies for local enterprises, and encourage enterprises to develop new technologies and improve energy efficiency to improve air quality.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.SN and YF: conceptualization and visualization. SN: methodology and software. RZ: validation and funding acquisition. YF: formal analysis. YC and YF: data curation, writing–review and editing, and supervision. YC: writing–original draft preparation. All authors have read and agreed to the published version of the manuscript.


Recently, Transformer-based video recognition models have achieved state-of-the-art results on major video recognition benchmarks. However, their high inference cost significantly limits research speed and practical use. In video compression, methods considering small motions and residuals that are less informative and assigning short code lengths to them  have successfully reduced the redundancy of videos. Inspired by this idea, we propose Informative Patch Selection (IPS), which efficiently reduces the inference cost by excluding redundant patches from the input of the Transformer-based video model. The redundancy of each patch is calculated from motions and residuals obtained while decoding a compressed video. The proposed method is simple and effective in that it can dynamically reduce the inference cost depending on the input without any policy model or additional loss term. Extensive experiments on action recognition demonstrated that our method could significantly improve the trade-off between the accuracy and inference cost of the Transformer-based video model. Although the method does not require any policy model or additional loss term, its performance approaches that of existing methods that do require them. The development of neural-network-based video models has improved the accuracy of video recognition. Recently, video models based on Transformers  have beeA great deal of information is shared in a spatiotemporal neighborhood of videos, making them highly redundant. This is because videos are represented as appearance and motion, and motions follow a distribution that is biased toward the spatial neighborhoods . Therefore, when a frame of a video is represented by motions and residuals from the previous frame, the areas with small motions and residuals are dominant. In video compression, the method considering such areas include little information content, and assigning short code lengths to them  has beeInformative Patch Selection (IPS), which efficiently reduces the inference cost of Transformer-based video models by excluding patches with little information content from the input. More precisely, IPS models the distribution of motions and residuals in a patch of a P-frame (Predicted frame) from an MPEG4-encoded video. Then, patches with a large probability are considered to have a small amount of information and are excluded from the input. IPS is simple and effective in that it can dynamically reduce inference cost depending on the input without requiring any policy model and complicated training, unlike the previous works .unsqueeze(0).expand# z_patch = z[1:].reshape# z = concat, axis=1)#  # reshape mask and pad it for classification tokenmask = concat, mask.reshape, axis=1) #  # get selected (not masked) indicesind = where(not mask) # — element-wise calculation —# calculate query, key and value for only selected indicesq, k, v = zeros, zeros, zerosq[ind], k[ind], v[ind] = fc_q(z[ind]), fc_k(z[ind]), fc_v(z[ind]) # — attention matrix calculation —# calculate attention matrix ”in parallel” along temporal-axis (axis=0)attn = (q @ k.transpose) / scale# mask = mask.unsqueeze(1).expand# attn = attn.masked_fill)attn = softmaxz = attn @ v#  # — element-wise calculation —# postprocessz = fc(z)z_cls = mean# averaging along temporal-axisz = concatz += z_prevz = MLP(LayerNorm(z))z_prev = zJoint Space-Time attention reduces the cost of both the attention matrix calculation and element-wise calculation by reducing the number of input patches, resulting in a significant reduction in the overall inference cost. In Divided Space-Time attention and Factorized Encoder, the attention matrix calculation has already been made more efficient. However, element-wise calculation still accounts for much of the computational cost. We can see that reducing the number of patches can significantly reduce the overall inference cost by reducing element-wise calculations. Note that because in Divided Space-Time attention the spatiotemporal relationship is modeled with two Transformer blocks, one in the temporal direction and the other in the spatial direction, the element-wise calculation is almost twice as large as that of Joint Space-Time attention.Attention matrix calculations, which increase computational complexity in proportion to the square of the number of elements, are frequently regarded as the largest bottleneck in cost-reduction efforts ,3. HowevIn a video, a great deal of information is shared in spatiotemporal neighborhoods; that is, a certain pixel value is often easily predictable from its neighborhood. This is due to the fact that videos are represented as appearances and their motions, and motions follow a distribution that is biased toward the spatial neighborhoods . In widely used video compression methods such as MPEG4 , a videok-th patch of P-frames created in the manner described in The (self-)information for the Finally, a set of patches whose self-information is above the threshold are selected as input: Motions and residuals for IPS are always non-accumulated ones.A problem arises when some of the patches represented by motions and residuals are excluded from the input using the method presented above. That is, it is often impossible to identify regions in an I-frame (appearance) that correspond to observed patches in a P-frame due to interruptions in the motion trajectories by unobserved patches. This means that the model may not associate appearances and motions or reconstruct the RGB values of the P-frame, which may lead to inaccurate video recognition. To solve this problem, we adopt the ”P-frame accumulation” proposed in . P-frameWe evaluate our method and perform comparisons with baseline models on action recognition benchmarks, where the methods are required to take a video as input and output the action class occurring in the video . This section describes the experimental setups; the results of an ablation study and comparisons to baselines and state-of-the-art methods; and discussions of these results.Here, we describe the datasets, evaluation settings and implementation details of our method, including preprocessing and training procedures. In addition, we present baselines prepared for comparisons to confirm the effectiveness of our method.HMDB-51  contains 3570 videos for training and 1530 videos for validation; they are labeled according to 51 action classes. The average duration of the videos is approximately 3.1 s.Something-Something V2 (SSv2)  includes 168.9k videos for training and 24.7k videos for validation; they are labeled according to 174 classes. The average duration of the videos is approximately 3.8 s.Mini-Kinetics  is a subset of Kinetics [Kinetics , which cWe used three datasets for action recognition:SSv2 is a relatively motion-intensive dataset, whereas HMDB-51 and Mini-Kinetics are more about appearance information. Therefore, we performed a detailed ablation study and comparisons to baselines using HMDB-51 and SSv2, and we conducted comparisons to state-of-the-art methods using HMDB-51, SSv2, and Mini-Kinetics.We used GFLOPs per video as a device-independent metric of each models’ inference cost . In addition, we measured the runtime of the models’ inference on both a CPU  and GPU, as well as the runtime of video decoding on CPUs. We used an AMD Ryzen 9 3900X 12-Core Processor as the CPU and an NVIDIA GeForce RTX 3090 as the GPU. We mainly compared the models’ inference costs, which does not include the process of decoding compressed videos nor of encoding frame images into compressed videos. We refer to models’ inference costs as the ”inference cost”, unless otherwise specified. The reasons for this are as follows: First, as mentioned in We used the official implementation of TimeSformer  pretrainTo efficiently take into account the long-term relationship, the entire video in the dataset was first re-encoded at 6 fps. The input was a clip of 24 frames  randomly extracted from the entire video for training and at the temporal center of the video for testing. We also applied spatial cropping to obtain a square region. According to [As a loss function for classification, we used cross entropy. We performed 15 epochs of training using stochastic gradient descent  with a mUniform space (uni space): The spatial indices of patches were sampled uniformly at equal intervals, and the patches with those spatial indices were excluded from the input in all the frames.Uniform time (uni time): The time indices of patches were sampled uniformly at equal intervals, and all patches in those time indices were excluded from the input.Uniform (uni): The spatiotemporal indices of the patches were randomly selected according to a uniform distribution and excluded from the input. Compared to uni space, the range of spatial indices that can be covered tended to be larger, because different spatial indices were allowed to be selected at different time indices. Similarly, compared to uni time, the range of time indices that could be covered tended to be larger.Frame subtraction (sub): Patches were selected if the average absolute subtraction from the previous frame was greater than or equal to a threshold value.Multiple patch selection baselines were prepared for comparison to confirm the effectiveness of IPS:The inference cost was adjusted by varying the sampling rate for uni space, uni time and uni and by varying the threshold for sub.First, we demonstrate the effectiveness of IPS in adjusting the inference cost for TimeSformer for each attention type. Notably, IPS is a more flexible and efficient way to reduce inference cost than the engineering attention matrix calculations such as Divided Space-Time and Factorized Encoder is in such a low-computation domain (note the comparison of the inverted triangles in the figure).Second, we show the trade-off between the accuracy and total inference runtime (including the models’ inference and video decoding processes) when using IPS on both CPUs and GPUs for each attention type in In addition, we show a comparison of the costs of video decoding and model inference in In this section, we explore four design choices for our overall approach, input modalities for the model and the use of P-frame accumulation, residuals and distribution fitting for IPS.without using IPS. P-frames can be represented as RGB, motions + residuals or motions + residuals with P-frame accumulation. The accuracies in the HMDB-51 and SSv2 datasets using each type of P-frame are shown in First, we examine which modality should be used to represent P-frames Equation ) or withChanging the resolution is another method of reducing the input size. better trade-off between accuracy and inference cost in the low-computation domain. These can be categorized into two types of approaches, static to input and dynamic to input. TSN [put. TSN , TRN [15put. TSN , TSMNet put. TSN ,17 and Mput. TSN  are statput. TSN , Dynamicput. TSN , FrameExput. TSN , LiteEvaput. TSN , SCSamplput. TSN , ARNet [put. TSN , VideoIQput. TSN  and Adafput. TSN ,37,38) iFirst, among the Transformer-based video models, which tend to be expensive, TimeSforer-S with IPS achieved a very lightweight inference cost . AlthougOn the HMDB-51 dataset, which contains only a relatively tiny amount of data, the accuracy of TimeSformer-S is below the level of accuracy of CNN-based models . This isWe propose IPS, a method to efficiently reduce the inference cost by excluding redundant patches from the input of a Transformer-based video recognition model. Inspired by video compression, we define the redundancy of a patch using motions and residuals, which we obtain while decoding a compressed video. Extensive experiments on action recognition demonstrated that our method could significantly improve the trade-off between the accuracy and inference cost of a Transformer-based video model. Despite its simplicity, the efficiency of the model equipped with IPS approaches that of more complicated existing methods requiring policy models or additional losses.This research is a pioneering attempt to develop a method that takes a compressed video as input and adjusts the inference cost based on the amount of its information. We believe that our idea and experimental results will open up new possibilities for improving the efficiency of Transformer-based video models, which have the weakness of huge inference costs. Even though IPS assumes Transformer-based video models, the potential of which is not fully realized with the limited training data, it is expected that video datasets for training/pre-training will continue to grow in size, allowing Transformer-based video models to scale up in accuracy. One limitation of the proposed method is that currently it only supports the MPEG4 video codec. Even though MPEG4 is a widely used video codec in the real world, further support for other codecs will allow the proposed concept to have a wider range of applications. Specifically, we would like to support H.264  and HEVC


To reduce incidents of inpatient violence and aggression at Nile Ward Psychiatric Intensive Care Unit (PICU), St Charles Hospital by at least 30% between December 2019 and December 2021. Reducing inpatient violence is a major quality improvement (QI) priority for CNWL NHS Foundation Trust.Improved risk assessment tool: Risk assessment tool to predict/manage violence in the ward was further improved using evidence based observation and best practice recommendations over the course of 2021.Brand new Staff Photo Board: Regularly updated photoboard with non-hierachical list of all staff.Patient Feedback Board: Patient experience, comments and feedback displayed in common areas.Co-produced Mutual Expectations: A set of expectations created in co-production with patients displayed in the communal areas of the ward to be followed by both staff and patients.Gardening sessions: A safe socially distanced space for patients to be involved in growing and caring for the Nile Ward garden with our Activities Coordinator, including a brand new herb garden.Tailored Physical Fitness Programmes: Focus on physical activity through garden fitness sessions and 1–1 fitness sessions in the gym. Average weight gain for patients has declined from 4.4 kg to 2.8 kg (39% reduction) during hospital stay. Tailored physical fitness sessions created for patients who are frail, diabetic or have significant cardiometabolic risk factors.Celebrating Diversity: Special events hosted throughout the year to celebrate diversity and promote tolerance.Enhanced Clinical Reviews: Consultant led patient reviews every weekday to optimise treatment and enable quick recovery using a multidisciplinary, holistic, trauma informed approach.Weekly Cooking Sessions: Patient led cooking sessions using healthy ingredients every week. The food is eaten as a communal meal by patients and staff. A ‘Friday Fry-Up’ takes place monthly where patients and staff share a health fry-up in the ward's dining area.Mindfulness Meditation: A QI intervention introduced to embed mindfulness and meditation as core therapeutic intervention to improve emotional regulation and to reduce violence.Triangle of Care: Carers strongly encouraged to attend ward rounds and care planning from the very beginning of a patient's journey at Nile Ward using a triangle of care approach.Nile Ward refined a number of their successful change ideas within this project and a number of new innovative ideas were tested and successfully implemented as part of the Violence Reduction QI Project:Between December 2019 - December 2020, Nile Ward reduced violence in the ward by 35% and the MDT continued to make further innovations to reduce violence further, as demonstrated in this poster.Between December 2020 - December 2021, Nile Ward reduced violence in the ward by 51%.Further details about the results will be published in the poster.Nile Ward has successfully implemented innovative interventions using a QI methodology to successfully reduce the level of violence and serious incidents in the ward by 51%. The number of rapid tranquillisations and use of restrictive interventions such as restraints has reduced significantly. Our patients are able to recover in a safe environment and their feedback is testament to their positive patient experience during their inpatient stay. Reduced verbal and physical assaults on staff have improved staff confidence, retention, well-being and overall satisfaction. Our work has been recognised internationally through the delivery of keynote presentations at conferences National Association of Intensive Care Unit (NAPICU) National Conference 2021 & the Royal College of Psychiatrists National QNPICU Conference 2021 to discuss their Violence Reduction best practices with mental health teams in the United Kingdom and abroad.