People aged 75 years and over account for 1 in 4 of all hospital admissions. There has been increasing recognition of problems in the care of older people, particularly in hospitals. Evidence suggests that older people judge the care they receive in terms of kindness, empathy, compassion, respectful communication and being seen as a person not just a patient. These are aspects of care to which we refer when we use the term ‘relational care’. Healthcare assistants deliver an increasing proportion of direct care to older people, yet their training needs are often overlooked.This study will determine the acceptability and feasibility of a cluster randomised controlled trial of ‘Older People’s Shoes’ a 2-day training intervention for healthcare assistants caring for older people in hospital. Within this pilot, 2-arm, parallel, cluster randomised controlled trial, healthcare assistants within acute hospital wards are randomised to either the 2-day training intervention or training as usual. Registered nurses deliver ‘Older People’s Shoes’ over 2 days, approximately 1 week apart. It contains three components: experiential learning about ageing, exploration of older people’s stories, and customer care. Outcomes will be measured at the level of patient , healthcare assistant (empathy and attitudes towards older people), and ward . Semi-structured interviews of a purposive sample of healthcare assistants receiving the intervention, and all trainers delivering the intervention, will be undertaken to gain insights into the experiences of both the intervention and the trial, and its perceived impact on practice.Few training interventions for care staff have been rigorously tested using randomised designs. This study will establish the viability of a definitive cluster randomised controlled trial of a new training intervention to improve the relational care proided by healthcare assistants working with older people in hospital.ISRCTN10385799) on 29 December 2014.The study was registered as an International Standard Randomised Controlled Trial ( Older people account for a large and increasing proportion of those receiving National Health Service (NHS) acute care. In England in 2013, people over the age of 75 years accounted for 24 % of all hospital admissions, an increase of 57 % over the previous decade with the average hospital stay for this age group decreasing from 15.2 to 9.4 days [Just under a fifth of respondents to the NHS Inpatient Survey did not feel that they were treated with respect and dignity at all times  and in cWhile patient-centred care is an explicit priority, there is a lack of clarity among staff at all levels as to what this actually means and how it can be practically implemented . EmotionThe focus of the proposed study is the relational care provided to older people in hospital. Relational aspects of care include dignity, empathy and emotional support as distinct from functional or transactional aspects of care . In a rePerhaps due to the nature of the work they do, nurses have often been targeted as both the source of the problem and the solution to concerns about loss of dignity for patients in hospital . HoweverAlthough investments in staffing and work environments are pre-requisites for high-quality care , 19, hisTraining of HCAs has hitherto been ad hoc, variable, and marked by a tendency to focus on tasks and competencies, with little attention paid to relational care. The importance of using principles of instructional  design  to develTo date, evaluations of training interventions for HCAs have been few, are typically lacking any comparative element (e.g. ), and arThe aims of the study are to assess the feasibility of a cluster randomised controlled trial to compare the performance of an HCA training package in relational care against current training in improving the care of older patients in acute NHS settings, and to explore optimal methods for cost-benefit analysis for a definitive study.The acceptability of the intervention to trainers and HCA trainees.The willingness of ward managers, HCAs and older patients to participate in a cluster randomised controlled trial.The willingness of ward managers for wards to be randomly allocated.The level of non-response and item non-response to outcomes at the level of ward, HCA and patient.The acceptability of outcome measures to participants.The ability to monitor levels of resource-use and quality of life data.The variability within and between ward, HCA and patient outcomes.The appropriateness of ward as the unit of randomisation.Important parameters that are needed to inform the feasibility of a definitive trial   will be A pilot cluster randomised controlled trial will be conducted to compare an ‘HCA training package in relational care’ with ‘HCA training as usual’. Clusters are wards within three acute NHS Hospital Trusts in England with outcomes observed at the level of ward, HCA and patient Fig. .Fig. 1CaGeneral medical, stroke or wards for the care of older people are eligible to enter the trial. Specialist dementia wards and medical admissions units are excluded.HCAs employed full time or part time within enrolled wards are eligible to enter the trial. Those employed as bank staff and not part of the named staff on the ward roster are ineligible.Patients will be eligible if they are aged 70 years or over and discharged from an inpatient stay on an enrolled ward, during either the 4-week period prior to randomisation (baseline) or during weeks 9 to 12 post-randomisation (follow-up). Patients transferred to another ward or hospital prior to discharge or considered by the nurse-in-charge not to have mental capacity  or to be in the final stages of a terminal illness are excluded.n = 12 wards in total).The ward manager provides permission for ward participation. Recruitment of wards will cease once permission is given by ward managers of 4 eligible wards from each of 3 acute NHS Hospital Trusts  receiving inpatient care from the enrolled wards in the 4-week baseline period and the 4-week follow-up period will be identified by a hospital-based research nurse in consultation with ward managers. Informed consent will be obtained from all patient participants. The research nurse will approach each of the patients meeting eligibility criteria, explain the study, and provide the patient with a participant information sheet. If they agree to receive a questionnaire after discharge from hospital, the research nurse will ask them to sign a consent form.To assess quality of interactions within a ward the Quality of Interaction Schedule (QUIS) observation tool is used by a trained observer at each hospital . QUIS isAt baseline, HCAs receive a self-completion questionnaire containing the Assessment of Work Environment Schedule (AWES), , 31 the At 2 weeks after discharge from hospital, patients who have consented to participate receive a questionnaire and pre-paid addressed envelope. To assess the relational aspects of care experienced by patients, the Patient Evaluation of Emotional Care during Hospitalisation (PEECH) , 35 is uStratified by NHS Hospital Trust, 12 wards will be randomly allocated by the Norwich Clinical Trials Unit. Each ward has an equal chance of receiving either training for HCAs in relational care or training as usual. Random allocation is generated via computer-written code. To conceal allocation from those responsible for recruitment, randomisation takes place immediately after baseline measures are completed and 4 weeks ahead of the start of the intervention (set-up period) to allow appropriate arrangements including HCA cover.n = 6 wards, 2 wards per hospital) will receive ‘Older People’s Shoes’, a newly developed HCA training package that focuses on the relational care of older people. The training intervention was developed using evidence from interviews with HCAs, other ward staff, older people, and a panel of experts. The intervention development work was funded by the same grant but in an earlier phase of this project. Course materials comprise a trainer manual and trainee workbook, PowerPoint resources and an online version of the training.HCAs from wards randomised to the new training intervention  of hospital care. Experiential learning is provided through learners having the opportunity to use age simulation suits.Getting to know older people.This unit challenges HCA participants to think about how hospitalisation can strip away much of what makes people individual; and how stereotypical notions of ageing may lead care staff to make false or limiting assumptions about older people. It looks at how opportunities can be found to ‘discover the person behind the patient’ through life stories, and so build stronger relationships with the older people they care for.Learning from customer care.This unit asks HCA participants to consider how some aspects of customer care provided in non-health settings can be applied to their work in the ward. This includes ‘active listening’ and reading body language to try to understand what may lie behind the behaviour of patients that are seen as ‘difficult’; and how to deal with angry patients or visitors. The aim is that learners will come to understand how relatively simple techniques can be incorporated into their own practice. The unit also addresses the need for HCAs to look after themselves.Training comprises three units relating to the care of older people in hospital:Each unit is divided into two sessions, one per day, so that learning on the first day can be consolidated and developed during the second day. At the end of Day 1 HCAs are asked to undertake brief individual work-based exercises prior to Day 2. Additional materials are also available online with access restricted to HCAs allocated to the training intervention.Authenticity – activities are directly relevant to the participant HCA’s role in caring for older people in hospital.Active learning – group exercises are embedded throughout to maintain HCA participant engagement and ensure learning is active rather than passive.Drawing on experience – HCA participants are encouraged to think about what happened to them in particular situations, how it felt, how they reacted, what resulted, and what they observed.Provision of mechanisms for connecting experience to future opportunity – HCA participants are encouraged to reflect on their participation in learning activities to make their experiences relevant to their future work with older people.Training seeks to promote empathy with older patients, give time for reflection and shared experience, affirm the importance of the HCA role, and ensure that HCAs know how to access their local support network for any issues that may arise as a result of the training intervention. Given the practical, hands-on nature of much of an HCA’s work, the overarching theoretical basis for the training package is derived from Carver’s framework for understanding experiential education . Carver’The pedagogical approach used to inform the design of the training intervention was Gagne’s nine-step model   will receive ‘training as usual’. This is typically restricted to periods of staff induction or focussed on mandatory training requirements such as manual handling. HCAs will receive no training in relational care beyond any that might be experienced as part of the standard process within their employing NHS Hospital Trust. Educational leads for each NHS Hospital Trust have provided details of how this is operationalised for HCAs within their organisation.HCAs from wards not randomised to the training intervention  will be observed during weeks 9 to 12 after randomisation. The primary outcome is at the level of patient (PEECH score).Between weeks 9 and 12 post-randomisation, 8 observations per ward will be conducted using identical methods to those used in the baseline period.HCAs will receive the TEQ and AGED inventory twice during the follow-up period, at weeks 9 and 12 post-randomisation.Patients due to be discharged from enrolled wards between weeks 9 and 12 post-randomisation will be approached, recruited and administered questionnaires in an identical way to that used in the baseline period.HCA staff in the intervention arm will be asked in the follow-up questionnaire whether the average duration of their patient contact times has changed since they received the training in relational care. Ward records will be used to ascertain the number of days patients stayed in the ward. Associated analysis will focus on completion rates in order to identify the feasibility of collecting such data, and inform the design of any future definitive study. Appropriate unit costs (e.g. Curtis ) will alFollowing the delivery of the intervention, trainers will be asked to undertake a semi-structured qualitative interview. These interviews will follow a topic guide covering specific aspects of delivering the intervention and more general aspects about learner engagement. Directly after the follow-up period a sub-sample of HCAs who have undertaken the training intervention will be asked to undertake a semi-structured qualitative interview. These interviews will follow a topic guide covering experiences of both the training intervention itself and being part of the pilot trial.All qualitative interviews are expected to last between 30 and 45 minutes. They will be conducted by a member of research staff, and be audio-recorded if given permission to do so by the interviewee.As the study is to test feasibility and is a pilot cluster randomised controlled trial, it is not powered to determine superiority of HCA training in relational care or training as usual.Observations by a researcher employed on the grant will take place on the four enrolled wards at each participating NHS Hospital Trust. For each ward, eight observations will take place during the baseline period and eight during the follow-up period. Each observation will last for 50 minutes.All eligible HCAs will be invited to take part. Numbers of HCAs employed on wards varies within and between NHS Hospital Trusts. Assuming approximately 10 HCAs employed on each enrolled ward, and an estimated recruitment rate of 70 %, it is anticipated that 84 HCAs will be recruited (42 per arm). A total of 12 HCAs from the intervention arm will be invited to take part in a semistructured interview. Anticipating that there will be some shortfall between recruitment to training and uptake of training, this number represents approximately one third of expected trainees. Requesting interviews with a greater number would put undue strain on ward staffing levels. Of those HCA trainees who give initial consent to interview, purposive sampling will be used to select across NHS Hospital Trusts, and to maximise variation of interviewees in terms of gender and length of experience.It is anticipated that across all 3 NHS Hospital Trusts 100 patients will receive questionnaires during the 4-week baseline period and a further 100 patients will receive questionnaires during the 4-week follow-up period.All trainers  who deliver the training intervention will be asked to take part in follow-up semi-structured interviews.All training intervention sessions will be observed by at least one member of the research team. Deviations from the trainer guide will be recorded. In addition, one member of the research team will observe the training intervention being delivered at each of the three centres to record differences in delivery between trainers. For those HCAs who attend the training intervention days, the number of days actually attended will be recorded.Within the analysis plan, the emphasis will be on the estimation of parameters required for a future sample size calculation and potential differences via confidence intervals, rather than formal hypothesis testing.QUIS will be analysed as a total mean rating for each observed session. Analysis will be based on the change from baseline to outcome using a general linear model including NHS Hospital Trust as this was a stratification variable. Due to the small number of wards this analysis will be descriptive.The outcomes of TEQ and AGED will be assessed using a linear mixed-effect model, with fixed effect being the intervention and the random effect will be ward. This will account for the potential of dependence of HCA-level responses from HCAs within the same ward. Additionally, the baseline value of the outcome will also be included as a fixed effect in a sensitivity analysis. These models will allow the estimation of the parameters required, including the within-ward and between-ward variance, for the planning of future trials, including the HCA-level variation and between-ward variation.Due to the small number of clusters, the results of the random-effect model will also be compared to those using a generalised estimating equation (GEE) model. Additionally, as the number of clusters is less than 15 per arm , sensitiAll analysis will be based on the intention-to-treat principle, including all recruited patients from within randomised wards. The total PEECH score will be analysed using a linear mixed-effect model with fixed effect being the intervention and the random effect will be ward in order to account for the potential of dependence of patient-level responses from patients within the same ward. The four subscales will be analysed using the same model. These models will allow the estimation of the parameters required for the planning of future trials, including the patient-level variation and between-ward variation. As with the HCA-level analysis, for the patient-level outcomes we will compare results from the random-effect model with those from a GEE model. The sensitivity of the assumption of a normally distributed outcome will be assessed using the two-stage non-parametric bootstrap.If appropriate, sensitivity of the results to missing data will be checked via multiple imputation. If appropriate, adjustment for baseline factors will be made.The qualitative interview data will be analysed thematically. As the purpose of these interviews is to inform the understanding of the process of both the trial and the delivery and receipt of the intervention, we will use framework analysis . This isA Trial Steering Committee (TSC) will monitor and supervise the pilot cluster randomised controlled trial in accordance with National Institute of Health Research Health Services and Delivery Research (NIHR HS&DR) Research Governance Guidelines for Trial Steering Committees (May 2013). The TSC comprises: Professor Karen Spilsbury, (TSC independent chair); Professors Antony Arthur, Jill Maben and Heather Wharrad (study co-applicants); Professor Jackie Bridges, Dr Tanis Hand, Dr Gail Adams, Dr Bev Fitzsimons and Dr Lynne Williams (expert advisors), Mrs Margaret McWilliams, Mrs Janet Gray and Ms Sagila Thiruthanikasalan ; Dr Ines Mesa Eguiagaray (independent statistician), Dr Ella Zomer .A favourable ethical opinion for this study  Protocol v2 9.2.2015) was granted by Cambridge South Research Ethics Committee on 13 February 2015 . Full NHS Research and Development approvals were granted for each study site . The study has been adopted onto the UK CRN portfolio (study ID UKCRN18280).We have made the following modification to the trial. Our ward observational tool is now the QUIS rather than the Care Kindness and Compassion Observation Tool  as origiTo date, 12 wards have been enrolled into the study, 112 HCAs have consented to take part and 115 patients have consented to receive questionnaires.


Near work is associated with increased activity in the neck and shoulder muscles, but the underlying mechanism is still unknown. This study was designed to determine whether a dynamic change in focus, alternating between a nearby and a more distant visual target, produces a direct parallel change in trapezius muscle activity. Fourteen healthy controls and 12 patients with a history of visual and neck/shoulder symptoms performed a Near-Far visual task under three different viewing conditions; one neutral condition with no trial lenses, one condition with negative trial lenses to create increased accommodation, and one condition with positive trial lenses to create decreased accommodation. Eye lens accommodation and trapezius muscle activity were continuously recorded. The trapezius muscle activity was significantly higher during Near than during Far focusing periods for both groups within the neutral viewing condition, and there was a significant co-variation in time between accommodation and trapezius muscle activity within the neutral and positive viewing conditions for the control group. In conclusion, these results reveal a connection between Near focusing and increased muscle activity during dynamic changes in focus between a nearby and a far target. A direct link, from the accommodation/vergence system to the trapezius muscles cannot be ruled out, but the connection may also be explained by an increased need for eye-neck (head) stabilization when focusing on a nearby target as compared to a more distant target. Near work, e.g. working on a computer, is associated with musculoskeletal disorder and pain in the area of the neck and shoulders –5. DespiTwo of the previous experimental investigations required the subjects to focus on a nearby target continuously, without interruption, for five and seven minutes respectively. The first investigation revealed a positive general correlation between eye lens accommodation and trapezius muscle activity . The secSince eye lens accommodation is driven by activity in the ciliary muscles, a direct parallel change in trapezius muscle activity due to changes in eye lens accommodation could hypothetically involve the ciliary muscles. When clear vision is acquired an efferent signal is sent to the ciliary muscles to alter the refractive power of the eye lens; a copy of this signal could be sent to the trapezius muscles and/or other muscles in the neck/shoulder area in order to stabilize gaze (cf. ).Patients with visual symptoms often report discomfort and pain in the neck/shoulder area . In schothe subjects’ trapezius muscle activity amplitude should be higher during a period of near focusing than during a neighbouring far focusing period,there should be a positive co-variation in time between accommodation and trapezius muscle activity during the Near-Far task.Trapezius muscle activity is higher when focusing on a nearby than on a more distant target, thereforeFor viewing conditions requiring more eye lens accommodation, i.e. more activity of the ciliary muscles, the effect on trapezius muscle activity and the co-variation in time described in hypothesis (i) should be more pronounced.The hypotheses were tested separately on healthy controls and on patients with a history of visual and neck/shoulder symptoms.The purpose of this study was to investigate whether a dynamic change in focus produces a direct parallel alteration in trapezius muscle activity. An experimental study was designed with a Near-Far visual task where subjects alternately focused on a nearby and on a more distant target requiring more and less extensive eye lens accommodation, respectively. The Near-Far task was repeated three times under different viewing conditions; one condition with no trial lenses, one condition with negative trial lenses to create increased accommodation, and one condition with positive trial lenses to create decreased accommodation. The hypotheses were:Data for this study were collected as a part of a larger study examining visual stresses on musculoskeletal loads . This reSeventeen women and nine men with a mean age of 29 years  participated in this study. Fourteen of these subjects were healthy and formed the control group. Twelve had a history of eye disorders (asthenopia) and non-specific neck disorders and formed the patient group. The age distribution within groups is presented in All subjects in the control group underwent a regular optometric examination and were deemed to have normal unaided or aided vision, normal near point of accommodation and convergence, and no history of eye disease.The patient group had been referred to an orthoptist for investigation and treatment. The orthoptic investigation included tests of stereoscopic vision, strabismus, near point of accommodation and convergence, and a complete refraction in cycloplegia. Eye disorders in the patient group ranged from uncorrected refractive errors  and insufficient accommodation, to neuromuscular anomalies such as heterophoria, heterotropia, and insufficient convergence. All significant refractive errors found by the orthoptist were corrected for using spherical and cylindrical glasses, all orthoptic treatment were completed and all patients were free from visual symptoms in the two to three months prior to study participation. At the time of the study, all patients rated some neck problems using the Neck Disability Index (NDI) . The NDIAll subjects were given verbal and written descriptions of the experimental protocol and signed informed consent form prior to participating in the study. The study was approved by the Medical Ethical Review Board of Uppsala University (2006:027), and was conducted according to the Declaration of Helsinki.The study protocol began by assessing subjects, binocularly, for refractive errors using an auto refractor  . Next, sSubjects performed a visual Near-Far task under three viewing conditions. The Near-Far task involved focusing back and forth between two targets, a Near and a Far target in a shape of an X . The twolook at the target, keep it clear, and indicate when you perceive blur and/or diplopia…”. The Near target was then moved towards the subject until he/she reported blur and/or diplopia. This was repeated five times and the average stopping point was used as a measure of the individual’s near point of accommodation (expressed in D). The estimated near points of accommodation were, in general, consistent with the expected age appropriate near point. Mean near point of accommodation and mean distance to the Near target is presented in An individual’s near point of accommodation (NAD) was determined as follows: the subject’s vision was corrected according to the auto refractor analysis and the Near target was presented at approximately 1 m. The subject was instructed to “…Neutral—no trial lenses, Negative—wearing—3.5 D trial lenses to create increased accommodation, Positive—wearing +3.5 D trial lenses to create decreased accommodation. The individual spherical refractive error detected with the auto refractor (in steps of 0.25 D) was added to the power of the trial lenses. If the participant did not have any refractive error, a—0.25 D lens was added in order to blind the participant to the different viewing conditions. The trial lenses were then mounted in frames  and used during the Near-Far task repeats.Three viewing conditions were used to create different eye lens accommodation conditions as follows: During the Near-Far tasks eye lens accommodation was continuously recorded by the auto refractor at 25 Hz ,22. The First the default distance (1 m) was shifted to optical infinity:ity . The most stable 1.5 s window value for each Near and each Far period was saved if the window had a minimum of 15 out of 37 valid samples from the auto refractor. Then, a mean for Near and a mean for Far was calculated, if there were a minimum of 8 out of 15 period values. This process was repeated for each eye (right and left), and for each Near-Far task (2 x 2.5 minutes recording of accommodation), resulting in four estimates of accommodation response for each subject and each viewing condition. Since no differences were found in accommodation response between the first and second 2.5-min recording trial, or between the right and left eye (cf. ), a singFor periods containing only one valid signal (from either the right or the left eye), that signal was used for the co-variation analyses in time ; in periods with no valid signal, no data were used at all. Signals were band-passed filtered at 0.05–3 Hz. The cut-off frequencies were chosen to filter out variations (noise) that were unrelated to the Near-Far task accommodation.To validate the measurement from the auto refractor and to check that the subjects followed the instructions and changed focus between the two targets, the reaction time (RT) was calculated. RT was defined as the time between the shift in target  and the beginning of the shift in eye accommodation (i.e. when the accommodation decreased/increased in comparison with the accommodation level prior to the target shift) , and sampled at 2000 Hz  during all Near-Far tasks. Noise in the EMG signal caused by heart beats was reduced using the ECG signal as described by Widrow et al. (1975)  and modith percentile RMS EMG values were computed for Near and Far focusing periods, including values 1 s after target shift until 1 s prior to the next target shift. EMG from Near and Far target focusing was expressed as a percentage of the EMG level during Far target focusing (%Far) for each viewing condition; by this scale Far target focusing periods were 100%Far for all viewing conditions.To quantify muscular activity level during each viewing condition, 50Raw EMG signals from each 2.5 min trial during the Near-Far task were band-pass filtered 20–500 Hz, RMS-transformed (0.2 s window), interpolated to match the sampling frequency of the auto refractor signal (25 Hz), and band-pass filtered at 0.05–3 Hz for use in cross-correlation analyses with the auto refractor signals.Signal processing was performed using custom software written in MATLAB . Statistical tests were carried out with SPSS 20.0 for Windows . The level of significance was set at α = 0.05.Group (control and patient) mean values for the Near and Far focusing periods in the Near-Far task within each viewing condition were calculated for accommodation response and for trapezius muscle activity (EMG expressed in both %RVE and in %Far). For reaction time, group mean values within viewing condition and group were calculated for Near-to-Far and for Far-to-Near values . T-tests were run for each viewing condition and group.To test whether eye lens accommodation response and trapezius muscle activity co-vary in time during the Near-Far task, the cross-correlation function (R(time shift)) was computed for each viewing condition and group .This cross-correlation function computes the correlation coefficients between two signals by time shifting one of the signals. When the time shift is zero, the original signals are synchronized in time and the cross correlation function, R(time shift = 0), equals Pearson’s correlation coefficient, i.e. if two signals are identical, R(0) = 1. If these signals co-vary in time, R(time shift) will differ significantly from zero , negative condition 2.71 , positive condition 2.53 , and for the patients: neutral condition 1.82 , negative condition 2.36 , positive condition 1.74 .The trapezius muscle activity values (in %Far) within viewing condition and group are displayed in Mean percentage of valid samples for accommodation  from the auto refractor for the Near-Far task within viewing condition were for the control group: neutral 77% negative 77%, and positive 79%, and for the patients: neutral 83%, negative 78%, and positive 84%. The mean maximal cross-correlation and time shift (in seconds) for the two groups are displayed in For the control group the maximal cross-correlation differed significantly from zero for the neutral and the positive viewing conditions, but not for the negative condition. In the patient group none of the maximal cross-correlations differed significantly from zero. None of the estimated time shifts differed significantly from zero; neither in the control group nor in the patient group .Results of the paired sample t-test within the control group showed that trapezius muscle activity during Near focusing periods (in %Far) was significantly higher for the neutral than for the negative viewing condition (p = 0.013), but there were no significant differences in any other case ) there were no significant differences among viewing conditions, neither within the control group (p > 0.441), nor within the patient group (p > 0.22).During the Near-Far task the amplitudes of the trapezius muscle activity were higher when focusing on a nearby than on a distant target. This difference was significant for the neutral viewing condition for both controls and patients. Furthermore, there was a significant cross-correlation between trapezius muscle activity and eye lens accommodation during the Near-Far task within the control group for the neutral and the positive viewing conditions, but not for the negative condition. In the patient group none of the maximal cross-correlations differed significantly from zero. There were no signs of pronounced effects for viewing conditions requiring more eye lens accommodation, neither on the trapezius muscle activity nor on the cross-correlation.The cross-correlation between trapezius muscle activity and eye lens accommodation during the Near-Far task within the control group for the neutral and positive viewing conditions was small, but statistically significant. None of the time shifts were significantly different from zero. The cross-correlation curves within the control group for the neutral and the positive viewing conditions exhibited a wave pattern with maxima occurring at times that were consistent with the mean interchange time between Near and Far focusing periods (5 s) Fig  and 6e. A theory mentioned in the introduction, suggests that a direct link between accommodation and trapezius muscle activity could involve the ciliary muscles: When clear vision is needed an efferent signal is sent to the ciliary muscles to alter the refractive power of the eye lens, a copy of this signal could be sent to the trapezius muscle and/or other muscles in the neck/shoulder area in order to stabilize gaze . If this link exists, we would likely see a pronounced effect both on trapezius muscle activity and on cross-correlation for the negative viewing condition which required more activity in the ciliary muscles. In this sample of data there was no sign of a pronounced effect within the negative viewing condition. Instead it was the neutral viewing condition, with a slightly lower mean accommodation response than the negative condition cf. , that shA study by Kapoula et al. (2006) showed decreased body sway during near focusing when the eyes converged more, than during far focusing with less demands on convergence. One suggestion arising from those results was that oculomotor signals and gaze related activity in the neck muscles are involved in postural stability . A more In line with the above suggestion, and since the visual system has little tolerance to errors in convergence , a relevAs described above, the negative viewing condition created incongruence between vergence and accommodation which altered the natural couplings between accommodation and convergence. The positive condition was also hard for the visual system, a positive +3.5 D blur is almost impossible to overcome. Even though the attempt to create increased and decreased levels of accommodation failed to show any linear association between accommodation response and trapezius muscle activity, a direct link between eye lens accommodation and trapezius muscle activity cannot be ruled out. Another explanation for the increase in muscular activity during near focusing could be the necessity for eye-neck (head) stabilization; a head movement in the frontal plane results in a relatively large change in visual degrees when focusing on a nearby target, while for a distant target, the visual angle will remain almost unchanged. This suggestion is analogous to the coordination of eye and neck muscles when shifting gaze . IndividDuring the experiment, the subjects were seated in an office chair in a slightly leaned back position supported by a combined head and backrest adjusted to their morphology. They were instructed to keep this posture throughout the experiment. This was necessary in order to measure eye lens accommodation with the auto refractor. Consequently, the head and neck were externally stabilized, and therefore there was no real need for increased muscle activity in muscles involved in eye-neck (head) stabilization. Still, significant muscular activity increases were seen. These increases might have been larger without the external support.The upper trapezius muscle can be monitored easily with surface EMG, is a common site for work-related pain, and has been the focus of much research on EMG signals in relationship to sedentary work, such as computer work . HoweverThe controls had significantly higher accommodation responses during Near focusing within the negative condition than the patients. Here it should be noted that the patients near point of accommodation was lower, which resulted in a slightly longer mean distance to the near target . The oriThe patients also all had self-reported unspecific neck/shoulder discomfort of unknown origin. This heterogeneity in the patient group might have affected the results of the study. In the patient group, the maximal cross-correlation was not significantly above zero for any condition, but the group mean cross-correlation curves showed the characteristic waveform in the neutral and positive conditions. In addition to the suggestion above, that the non-significant cross-correlation results in the patient group might be a sign of an altered function in the visual stabilisation process involving eye-neck (head) interactions, it may also be due to the heterogeneity in the group, and/or a lack of power in the analysis. In retrospect, it would have been an advantage to (a) increase the number of subjects in the patient group to increase power in the analysis, (b) to have a homogenous patient group with similar visual problems, and (c) to use a standardised physical examination method ,39) to dAccommodation to a visual target involves an average reaction time of approximately 0.5 s  . Mean reUnder working conditions that induce low demands on muscles, muscle activity amplitude varies slowly with time. To isolate the effect of Near and Far focusing on trapezius muscle activity, we used short time periods in our task, which effectively reduces the variance in comparison to longer Near and Far periods. Moreover, muscle activity during Near was normalised to the adjacent Far period, to obtain individual Near-Far ratios prior to the averaging.All average maximal R-values of the cross-correlation curves were less than 0.05 cf. . Both thOur present findings reveal that trapezius muscle activity is higher when focusing on a nearby than on a distant target, and that there is a co-variation in time between eye lens accommodation and trapezius muscle activity during dynamic changes in focus between a nearby and a far target. The effect on trapezius muscle activity was significant for the neutral viewing condition for both the control group and the patient group. In addition, the cross-correlation was significant for the neutral and the positive viewing conditions within the control group. A direct link, from the accommodation/vergence system to the trapezius muscles cannot be ruled out, but the connection may also be explained by an increased need for eye-neck (head) stabilization when focusing on a nearby target as compared to a more distant target.S1 File(XLSX)Click here for additional data file.


Raphia hookeri, Arecaceae) by wild chimpanzees (Pan troglodytes verus) at Bossou in Guinea, West Africa, from 1995 to 2012. Chimpanzees at Bossou ingest this alcoholic beverage, often in large quantities, despite an average presence of ethanol of 3.1% alcohol by volume (ABV) and up to 6.9% ABV. Local people tap raffia palms and the sap collects in plastic containers, and chimpanzees use elementary technology—a leafy tool—to obtain this fermenting sap. These data show that ethanol does not act as a deterrent to feeding in this community of wild apes, supporting the idea that the last common ancestor of living African apes and modern humans was not averse to ingesting foods containing ethanol.African apes and humans share a genetic mutation that enables them to effectively metabolize ethanol. However, voluntary ethanol consumption in this evolutionary radiation is documented only in modern humans. Here, we report evidence of the long-term and recurrent ingestion of ethanol from the raffia palm ( Anecdfacility ,5. Empirfacility . Howeverfacility  argued bet al. [Despite the apparent rarity of ethanol ingestion among non-human primates in nature, ethanol consumption occurs in every modern human society that has access to fermentable raw materials . Hence, et al.  resurrecet al.  experien2.Raffia palms, which occur naturally in seasonally flooded areas , are traevent from when an individual inserted a drinking tool into the container until that individual ceased drinking and descended to the ground. We defined a drinking session from when the first individual of a party started to drink until the last remaining chimpanzee at the top of the crown ceased drinking and descended the palm. Within a drinking session, we analysed drinking events per individual. Individuals of 12 years and older were classified as adults, and individuals aged less than 12 years were classed as immatures [Local harvesters are fully aware of the increased risks of tapping raffia palms within the chimpanzees' home range area, but do not remain in proximity to the palm throughout the day, making it difficult to guard against chimpanzee feeding. Over the years, Bossou researchers have witnessed chimpanzees ingesting the palm sap; several individuals sometimes take part in a single drinking session. Each individual was coded for only one event per session (for independence of data-points). We defined a drinking mmatures . Infantsmmatures . The dur−1  and immatures averaged 9.7 dips min−1 . Tonooka [Chimpanzees use leaves as tools in various contexts. To ingest fluids, chimpanzees often use leafy tools, a technique that is ubiquitous among wild chimpanzee communities . An indi Tonooka  calculat Tonooka ,19. For  Tonooka ,18,19, win situ at the morning harvest (06.00–08.00 h), and every 2 h thereafter, until the evening harvest (16.00–18.00 h), and hydrometer and refractometer readings were taken immediately. To ensure that calculations of ethanol quantities ingested by chimpanzees represented the time of day a chimpanzee drinking session occurred, we divided time of day into two categories: (i) high ethanol—08.00, 16.00, 18.00 h, where sap averaged more than 3% ethanol, and (ii) low ethanol—10.00–14.00 h where sap averaged below 3% (n=28), we calculated the approximate amount of ethanol ingested by each individual (ml). Means are presented with standard errors.We calculated the ethanol content ) of palm sap using refractometer (Zeiss) and hydrometer (SG) readings from 16 raffia trees occurring within the chimpanzees' home range. We collected samples at times when chimpanzees usually obtained the accumulated sap. Typical accuracy of these instruments is generally ±0.5% ABV. We took all measurements within the temperature limits of the refractometer and avoided direct sunlight. For each sample, 100 ml of palm sap was collected below 3% . During 3.F5,67=5.42, p<0.001; tree: F15,67=18.16, p<0.001).The ethanol content of palm sap collected from 16 raffia palms within the Bossou chimpanzees' home range averaged 3.1±0.2% ABV. Between 06.00 and 18.00 h, the maximum ethanol content recorded was 6.9% ABV . The elaOver 17 years, we observed 51 fermented palm sap drinking events recorded during 20 drinking sessions involving 13 adult and immature individuals . Chimpanzees always used a leaf tool to drink, making a crushed or folded leaf ‘sponge’ from the leaves placed as a protective covering by villagers or from plants growing nearby. This absorbent extractive tool was dipped into the small opening of the fermented palm sap container (see  for an eh−1 (i.e. three drinking sessions were observed in 1673 h of observation over a 12-month period) [s±103, n=28 events, six individuals), with individuals averaging 1.0±0.2 l of fermented palm sap per drinking event . Males accounted for 34 of the 51 events; however, one adult male in particular (FF) accounted for 14 of 51 events . The amount of ethanol ingested per event ranged from about 2.5 to 84.9 ml , with no sex difference . An individual that ingested a small quantity of palm sap in one drinking event could ingest a greater quantity in other events, and an individual that ingested a high quantity in one event was not averse to ingesting ethanol again shortly thereafter .Chimpanzees drank palm sap at a rate of 0.18 sessions 100  period) . Drinkin4.We document the first quantitative assessment of chimpanzees ingesting ethanol in the wild. Chimpanzees ingest fermented palm sap at Bossou rarely, but habitually. They use leaves to soak up and drink the sap, and like other chimpanzee communities that produce tools for drinking , the beFruits ferment naturally and regular ethanol consumption in the wild may be an unavoidable consequence of a frugivorous lifestyle. In the cases documented here, chimpanzees drank the fermented sap of raffia, and hence ethanol consumption was not a direct by-product of frugivory. Furthermore, raffia palm sap drinking is opportunistic, relying on a person having installed the specialized equipment to drain the sap from a mature palm. Other factors beyond the apes' control limit its exposure to fermented palm sap: raffia palms are scarce within the chimpanzees' core range (being mostly found in wetter areas of their range), and while a palm may produce fermented sap for several weeks, it dies after production.Raffia sap has a rich composition of vitamins and minerals , and proChimpanzees are intelligent, highly dextrous and variably technical; they use tools to access hard-to-reach food sources ,27. Lacket al. [Parinari spp. and Treculia africana, are often gathered by chimpanzees from the ground and eaten [Gorilla gorilla) and bonobos (Pan paniscus) would be useful to understand the conditions that favoured this molecular adaptation. Further palaeogenetic and ethological research may offer insight into potential subspecies and interpopulation differences in chimpanzees' ability to oxidize ethanol [Carrigan et al.  suggest nd eaten –30. Data ethanol . Relevan ethanol , the eth


When I was seven years old, my parents bought me and my brother a Nintendo Entertainment System, which they would eventually refer to as “The Idiot Box.” There was an implicit assumption  that video games were simply a toy and nothing of real substance could be gained from them. Considering this, and the prevalence of video games in society , a weakness and a strength , and a stage of its evolution (some Pokémon can turn into a new one if you used it enough). Roughly speaking, this gives us 5 distinct pieces of information per Pokémon and multiplying this by 150 gives 750 distinct units of information contained by the list of all the Pokémon in the first Pokémon game. Now let's consider another list of information that is considered more educationally important: the periodic table of the elements. Within the periodic table each element is defined by a symbol, a name, an atomic number and weight, a phase at room temperature, and its metal or gas type. That comes to 6 distinct units of information per cell. Multiplying this by 118, the total number of elements, returns 708 distinct units of information in the periodic table. What makes this interesting is that there are a large numbers of young children (and adults for that matter) who can recite, from memory much of the information contained in this list of Pokémon, but it would likely be difficult to find the same number of people who could do that for the periodic table. The point is that the medium of video games appears to have the potential facilitate significant learning.Let's consider a simple anecdotal example of how video games may encourage children to learn large amounts of information. Starcraft 2 (as well as its predecessors Starcraft and Starcraft: Brood War) is what is called a “Real Time Strategy” game. Players must obtain various resources and use them to purchase buildings and fighting units. Then, they must fight and defeat their enemy. To play this game successfully, players must manage their time and resources more efficiently than their opponents as each building and unit have a different cost, purpose, and build time. Additionally, much like Pokémon, units have strengths and weakness. A player has to constantly update their strategies throughout the game based on their interactions with the other players, requiring significant planning and critical thinking skills that are honed by players over time. In fact, while Starcraft beginners make less than 100 actions (or decisions) per minute, professionals can make over 400 per minute  to generate scores that would be used as dependent variables while teaching the students about factorial research designs. They found, based on a pre-test/post-test comparison, that students who played DDR as part of their lecture showed a greater increase in content knowledge compared to students who received a traditional lecture on the same topic. Even through the inherent content of DDR was not educationally relevant, clever pedagogical use of the game had the desired effect of increasing student engagement with the lecture content.Another way in which video games are learning machines Gee, , 2005 isMAge = 24.1; SAge = 3.8) on Super Mario 64 for 30 min a day for 2 months. Super Mario 64 is a game in which the player must explore the game world, fight monsters, solve puzzles, and collect stars to progress. Gray matter volume was measured pre- and post- training and it was found that the volume of gray matter in the right dorsolateral pre-frontal cortex was significantly increased post-training. There is evidence to suggest that an increase in cortical volume due to video game training is related to improvements in the concomitant cognitive functions of that brain region  about their gaming habits and their leadership experiences (both online and offline). The results revealed a positive correlational relationship between online leadership experiences and with offline leadership experiences (each measured using a different leadership questionnaire). While correlations only allow for a limited interpretation there is converging evidence to suggest that the video game play may be a causal or at least influencing factor. Yee  requires constant interaction and communication with other people. This interaction can take the form of a lecture, group assignments, study groups, or even general emotional and social support. An often overlooked aspect of video games is that they too can be a highly social experience. Despite this, a common misconception about video gamers is that they shun and avoid social engagement Jenkins, . Considetor. Yee , based oStarcraft 2, has a highly in depth competitive culture and multiplayer community (as do games like League of Legends and DOTA 2). Poling  play one of four games. In the interest of brevity, I will focus on only two. One of those games was called Lemmings and was chosen because they researchers deemed it a pro-social game. In this game, Lemmings drop from an entrance and walk forward unless there is something in their path, in which case they turn around. If the player does nothing, they will walk off the edge of cliffs and die. The purpose of the game is to guide the lemmings safely to the exits using a limited number of skills. It was deemed pro-social because the focus of the game is helping the lemming survive. The game Tetris was used as a neutral-social game. In this game, players must arrange geometrical shapes into horizontal lines to earn points. Players were asked to play their respective game for 8 min. After playing, they were presented with various social situations and their responses were recorded. The subjects were unaware that these were part of the study. In one study, the experimenter knocked some pencils onto the floor while talking to the subject. In another , a male confederate entered the room and verbally and physically harassed a female experimenter as if he were an ex-boyfriend who couldn't accept that their relationship was over. In both cases, the subjects who played the pro-social game were more likely to help the experimenter than the subjects who played the neutral game. The point is video games can have a positive influence on social behaviors (Durkin and Barber, World of Warcraft or Starcraft 2 can foster the social skills needed to coordinate and cooperate with other people, which could enhance student's ability to engage in group assignments.Video games have also been shown to be able to influence pro-social behaviors. Greitemeyer and Osswald  conductePortal, may improve problem solving skills, but do nothing to improve social skills or attentional processing. Multiplayer team games like League of Legends may improve the ability to communicate and cooperate with groups, but may not affect interest in learning more about school work. Historical simulation games, like the Civilization series might enhance a student's motivation to learn more about history, but have no influence over executive functions. It is therefore important to pick and choose the games you may want to use carefully. And second, video games cannot replace a teacher or a curriculum, but judicious use of the appropriate games can complement an educational program.Video games have significant potential as a pedagogical tool. In order to begin to explore this potential, the common preconceptions about what video games are and their value must be re-evaluated. In general, there are two rules of thumb that one should keep in mind when considering how to use video games in an educational context. First and foremost, it matters what games you are playing. Puzzle games like The author is a scientific consultant for a company that specializes in cognitive training video games.


Videoconferencing on mobile phones may enhance communication, but knowledge on its quality in various situations is needed before it can be used in medical emergencies. Mobile phones automatically activate loudspeaker functionality during videoconferencing, making calls particularly vulnerable to background noise. The aim of this study was to investigate if videoconferencing can be used between lay bystanders and Emergency Medical Dispatch (EMD) operators for initial emergency calls during medical emergencies, under suboptimal sound and light conditions.Videoconferencing was tested between 90 volunteers and an emergency medical dispatcher in a standardized scenario of a medical emergency. Three different environments were used for the trials: indoors with moderate background noise, outdoors with daylight and much background noise, and outdoors during nighttime with little background noise. Thirty participants were recruited for each of the three locations. After informed consent, each participant was asked to use a video mobile phone to communicate with an EMD operator. During the video call the EMD operator gave instructions for tasks to be performed by the participant. The video quality from the caller to the EMD was evaluated by the EMD operator and rated on a five step scale ranging from "not able to see" to "good video quality". Sound quality between participants and EMD operators was assessed by a method developed for this trial. Kruskal – Wallis and Chi-square tests were used for statistical analysis.somewhat difficult or very difficult to understand.Video quality was significantly different between the groups (p <0.001), and the nighttime group had lower video quality. For most sessions in the nighttime group it was still possible to see actions done at the simulated emergency site. All participants were able to perform their tasks according to the instructions given by dispatchers, although with a need for more repetitions during sessions with much background noise. No calls were rated by dispatchers as incomprehensible due to low sound quality and only 3% of the calls were considered Videoconferencing on mobile phones can be used for the initial emergency call during medical emergencies also in suboptimal conditions. Accidents, cardiac arrest and other medical emergencies are major contributors to death today,2. Lay bSeveral studies have examined the use of videoconferencing in medical emergencies. Video communication may improve the operators understanding of the callers situation, and thereby improve the instructions they give,6. In siPrevious studies on the use of video mobile phones during medical emergencies have been conducted under good light conditions and in quiet environments. Many calls to EMD centres come from poorly lit places, with varying degrees of background noise. When mobile phones are used for videoconferencing, loudspeaker functionality is automatically activated, which makes calls particularly vulnerable to background noise. Insufficient bandwidth may cause interruptions in the video flow, thus decreasing the usefulness of the image. A potential new video-based EMD service must take these aspects into account. We wanted to investigate if videoconferencing can be used between lay bystanders and EMD centres during medical emergencies under suboptimal sound and light conditions.Sound and video quality was tested during 90 sessions of a simulated medical emergency. In each session, a volunteer communicated through a video mobile phone with an EMD operator. We chose three different locations for the experiments in public areas in Tromsø, Norway, in order to assess whether different environments around the patient affect the perception of sound and video quality. Thirty calls were completed in each location; first 30 calls indoors in a shopping centre with good lighting and moderate background noise, then 30 calls outdoors next to a busy road during daylight and with much background noise, and finally 30 calls outdoors at night with poor lighting and minimal background noise. In total, 90 volunteers participated in one session each.Volunteers were recruited from a stand on each location and given oral and written information about the project. Persons not speaking Norwegian or who had seen others participate in the study were not included. After verbal acceptance to participate in the study, the volunteer filled out a form with information about age, gender, highest completed education, and whether they previously had called an EMD centre.Two fifth year medical students (SM and MH), played the role as either the EMD operator or the assistant on the medical emergency site. The latter recruited volunteers on the simulated emergency site, assisted the volunteer to set up a video call to the EMD centre through the mobile phone and made notes of comments from the volunteers. For each location the roles of the students were switched after 15 sessions.At the simulated medical emergency site a manikin  was placed on a table. A blanket and a cloth were placed next to the manikin, and a foreign body (coin) was placed in the manikin’s mouth Figure .Prior to the trial a sheet of paper containing patient information was generated for each session to be read by the volunteer. The patient information contained first name, surname, age and street address. The data used for generation of names was randomly chosen from Statistics Norway’s lists of female names and surnames used in Norway by 200 or more individuals. PatientThe Norwegian Index of Medical Emergency Assistance contains instructions to be given by EMD operators to callers. Ten sucOn the simulated emergency site we used a smartphone for communication with the EMD operator, the Apple iPhone 5 ™ , with a 1.3 Mega pixel front camera. We chose to only use the front camera as it is started automatically when the user initiates a videoconference, and it also allows the participants to see each other. The front camera has no flash and the transmitted image is therefore dependent on light from the surroundings. Videoconferencing on mobile phones can be used on either the 3G or the 4G mobile broadband. The 3G network provides a maximal upload/download speed of 10/10 Mbit/s, while the 4G network provides a maximal upload/download speed of 10/40 Mbit/s. We chose to disable the 4G transceiver as this network had limited coverage at the time of study.We simulated an EMD centre using an Apple MacBook Pro™  with a 1.3 Megapixel camera and a WiFi network with 10 Mb/s wireless upload and download speed. The EMD centre was not co-located with the simulated emergency site. In order to conduct video communication between phone and computer, we used the Apple FaceTime TM software , in which both audio and video signals are transferred over the internet.The EMD operator wrote down the information read by the volunteer . In order to use the portion of correctly recorded information as a measurement of sound quality, the EMD operator was not allowed to ask for repetitions of the patient information. The sound quality was also scored by the EMD operator on a five step scale ranging from "incomprehensible" to "very easy to understand". The EMD operator gave the volunteer two instructions, and the number of repetitions for each instruction to be performed correctly was recorded.The quality of the video from the caller to the EMD was evaluated by the EMD operator and rated on a five step scale ranging from "not able to see" to "good video quality". Additionally the EMD operator recorded any interruption in the video flow. The quality of the video from the EMD operator to the caller was not assessed.The notes from the EMD operator was compared to the patient information sheet from the simulated emergency site, with relation to patient name, age and address, and the registrations of the EMD operators rated as either right or wrong. Descriptive statistics were used to summarize data, and Kruskal – Wallis and Chi-square tests used for statistical analysis with an alpha level of 0.05. For calculation of chi-square, groups were joined due to small data sets. For statistical calculations, we used the software packages SPSS  and Excel .The volunteers received oral and written information about the study and how to contact the research group for questions or results, after which they gave an oral consent to participate in the study. Neither sound nor image from the conversations were recorded or stored. The forms that were filled out contained no information that could be linked to the volunteers and forms were destroyed at the end of the data collection. The regional ethics committee confirmed that ethical approval was not required for this project.indoors, daylight and nighttime groups. The groups differed regarding the level of education (p = 0.042), as the nighttime group had a higher proportion of participants with college or university degree.The median age of the volunteers were 31 years, 37% were females, 41% had previously called an EMD centre, and 63% had higher education . For all calls both instructions were completed correctly after a maximum of one repetition.somewhat difficult or very difficult to understand. No calls were rated as incomprehensible due to low sound quality . In most sessions the interruptions lasted less than one second, but in one session the number and length of interruptions made it difficult to see what was done at the simulated emergency site."I would feel reassured if the EMD operator could see whether I did the right things - and possibly correct me" , and "It felt right to see the operator in a situation like this" . One person commented on the extra time needed for the call to connect: "I would not like to wait for the phone to connect for the video communication in a stressful and critical situation" .During the experiments we received several comments from volunteers. Some commented on the reassuring aspect of visual communication: The quality of the video and sound was surprisingly good. This should be available soon" .We also received comments on the quality of the technology: "This study compared the quality of videoconferencing for volunteers communicating with an EMD operator in simulated medical emergencies at three different locations: indoors, outdoors with daylight and outdoors at nighttime. The EMD operator was able to see what was done in almost all scenarios, although with greater difficulty during poor light conditions. In spite of the great differences in background noise between the three groups, there was no significant difference in the EMD operator’s perception of sound quality. The volunteers were in all cases able to hear instructions from the EMD operator, although instructions were more often repeated for calls with much background noise.A measure of sound quality from the caller to the EMD was the number of information items  registered correctly by the EMD operator without asking for repetition of information. A low success rate can be interpreted as poor sound quality or disturbance (e.g. background noise). In today’s EMD service, sound is the only information channel between a caller and the EMD operator, which at times is challenging. We founThe sound quality from the EMD operator to the caller was measured as the need to repeat instructions to the caller. The need for repetitions was lowest in the nighttime group, which may be explained by less background noise in these sessions. Loudspeaker functionality has several advantages, as the caller can put the phone down and still hear what is being said, and the EMD operator can communicate with several persons at the same time. The latter has been perceived beneficial in other studies. Even winighttime group, where light conditions were poor, had the lowest quality. If camera light had been activated, results might have been better for the nighttime group. However, even a low quality-image has been described as valuable for the EMD operator in a previous study[nighttime group was rated as "not possible to see the execution of instructions".The video quality from the caller to the EMD was measured as the EMD operator’s subjective perception. There was a significant difference between the three groups, and the us study. In our In this study, we did not measure any time intervals - e.g. the duration of the sessions, the time until the first action was performed and the time used to connect the call. Previous studies have demonstrated some improvements in time factors and resuscitation quality when video conferencing has been used for simulated emergencies,7,10,11,During videoconferencing, low capacity of the network can lead to a partial loss of the video information, which is perceived as interference in the video image. This may lead to loss of important information and has earlier been a problem with videoconferencing on mobile networks with low bandwidth. In this study the EMD operator registered all cases of video disturbance, also those of short duration, and we found absence of this type of interference in almost 80% of the video calls. The EMD operator’s understanding of the situation was affected by video interference in only one of the ninety sessions.The demographics for the three groups were similar except for the level of education, which was higher in the nighttime group, which may partly explain why this group needed fewer repetitions of instructions. In this simulation study we did not want poor knowledge about the telephone to influence the results, therefore the assistant held the telephone used by the volunteer during most of the scenario. In a real setting less favourable results may therefore be expected. We did not standardize the distance between the mobile phone and the volunteer, which may have influenced the perception of both sound and video quality. The light conditions changed with the weather during the nighttime calls, which may have influenced the perception of video quality. If we had allowed for the use of the camera flashlight it may have given better image details and better results in poor light conditions. The order of the sessions in this trial was not randomized. The EMD operator may therefore have performed better during the last sessions due to learning. The roles as EMD operators were played by medical students without experience from real life EMD centres. Experienced EMD operators may have rated the quality of information from the volunteers differently. In spite of these study limitations, our study suggests that today’s mobile phones and networks transfers sufficient quality of video and sound for use during medical emergencies. Other communication technologies, such as other smartphones or networks and different communication software may give different results.Videoconferencing between lay bystanders and EMD operators can contribute to a richer communication than audio-only calls. Mobile phone videoconferencing activates loudspeaker functionality and makes the call vulnerable to background noise. This study has shown that it is possible to receive video during nighttime in poor light conditions, and that loudspeaker functionality can be used in noisy environments. We conclude that videoconferencing on mobile phones can be used between lay bystanders and an EMD operator during pre-hospital medical emergencies, also in suboptimal sound and light conditions.The instructions that were given to the volunteer were taken verbatim from the Norwegian Index of Medical Emergencies and rand1. Undress the patient immediately and as much as possible.2. Wrap a blanket around the patient.3. Place something soft under the head of the patient.4. Pull away from the patient.5. Keep the head of the patient stable in relation to body.6. Pinch the nostrils of the patient.7. Try to remove the foreign object from the mouth of the patient.8. Loosen the patient’s tight clothing.9. Wipe the nose and mouth of the patient with a cloth.10. Tilt the head of the patient gently backwards.EMD: Emergency Medical Dispatch; CPR: Cardio-Pulmonary Resuscitation.The authors declare no conflicts of interest.SM and MH have contributed to the conception and design of the study, acquisition and analysis of data and have drafted the manuscript. SRB has contributed to the conception and design of the study, has helped to analyze the data and has critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.SM and MH are both sixth year medical students at the University of Tromsø, Tromsø, Norway and cofounders of Forbedring Tromsø, a patient safety and quality improvement student organization.SRB  is a specialist in anaesthesiology at the University Hospital of North Norway, and a researcher in the Specialist Health Services at the Norwegian Centre for Integrated Care and Telemedicine, Tromsø, Norway. His research has contributed to the development of audio and video communication for medical emergencies.


While scratch cards are a popular, accessible, and inexpensive form of gambling, very little is known about how they affect and influence the player. This study sought to understand the physiological and subjective experience of scratch card play, with special emphasis on the effect of near-miss outcomes (i.e. uncovering two out of three “grand prize” symbols needed to win said prize), which are remarkably prevalent in scratch card games. Thirty-eight undergraduate students from the University of Waterloo each played two custom scratch card games and experienced three types of outcomes  while their skin conductance levels (SCLs) and post-reinforcement pauses were recorded. Each participant also rated each outcome in terms of its subjective level of arousal, valence, and frustration. Our results indicate that players interpreted near-misses as negatively valenced, highly arousing, frustrating losses, and were faster to move onto the next game following this type of outcome than following winning outcomes. Additionally, near-miss outcomes were associated with the largest amount of change in SCLs as the outcome was revealed. This work has implications for the problem gambling literature as it provides evidence of the frustration hypothesis of near-misses in scratch cards, and is the first study to examine the physiological and psychological experiences of scratch card players. Instant lottery games,Although scratch cards are typically grouped with lottery games at point of sale and within the gambling literature, some authors suggest that scratch cards represent a “harder” form of gambling due to their structural characteristics and the option of instantaneous and continual play , numerous studies have shown alarming rates of youth participation in lottery forms of gambling, suggesting that youth and adolescents continue to gain access these products , and large jackpots/top prizes. Indeed Ariyabuddhiphongs  encapsulImportantly both slot machines and scratch cards feature a particularly intriguing type of outcome—the near-miss. In gambling parlance, a near-miss is defined as an outcome that is close to a jackpot, but falls just short Reid . In a tyAs any scratch card player knows, scratch card near-misses are a very common outcome. For example, we purchased, five, two-dollar Cash For Life© scratch cards from an Ontario lottery retailer. These cards each contained three games (3 matrices of 6 or more symbols). In each game the player sought to uncover three identical symbols within the matrix to win the prize specified. The symbols were either dollar amounts  or the word LIFE (denoting the top prize). Thus, uncovering three $4.00 symbols would lead to a $4.00 prize, uncovering three LIFE symbols would lead to the grand prize ($200 per week for life). In these cards a near-miss would be two instances of the word LIFE being uncovered within a given game. Although the exact frequency of LIFE near-misses over the population of printed tickets is (to our knowledge) not known, every single card in our small sample contained at least one near-miss featuring the top prize. One of the purchased cards had LIFE near-misses in all three games on the card.Such near-misses are readily apparent to players because of low-level visual features. Within a game matrix, the majority of symbols are numerical amounts . By contrast, the grand prize symbol is the capitalized word “LIFE”. This symbol perceptually stands out from the other  symbols in the matrix. When two “LIFE” symbols occur in the matrix, they are likely to be noticed by players due to the combination of low-level features, and the fact that this symbol denotes the top prize. To appreciate how such near-misses may contribute to the allure of scratch cards, one must consider what is known about near-misses in another form of gambling—namely slot machine play.On a three-reel slot machine, one spins the reels and hopes for the best-case scenario—that three identical jackpot symbols  land on the payline. A classic near miss occurs when the first two reels stop with the red 7 s on the payline, with the third just above or below the payline (“7-7-X”). These outcomes are both highly salient and physiologically arousing  as anticipation builds. If after the outcome is revealed they consider the near-miss as a particularly frustrating kind of loss then they should show higher SCRs for these outcomes compared to either a loss or a small win. Importantly, players should show shorter PRPs following a near-miss than following a small win . One participant whose skin conductance data was out of range was excluded from only the SCR analyses. Finally, the winner of the top prize amount was not included in the analyses.M = 21.26). Prescreening ensured that participants were all: (1) 18 years of age or older , (2) experienced with scratch card type lottery games (3) not in treatment for problem gambling, and (4) and not currently in treatment for an anxiety disorder or taking any medication for an anxiety disorder. The latter restriction was used as some anxiolytic medication may interfere with the recording of skin conductance levels.The remaining thirty-five participants  ranged in age from 18 to 40  were approved by the University of Waterloo’s Office of Research Ethics.Participants played custom-made scratch cards Fig. . These cSubjective measures of arousal, valence, and frustration were administered using paper and pencil questionnaires. These measures documented participants’ ratings of each type of game outcome  in terms of the three dimensions described above. Arousal and valence were measured using Self-Assessment Manikins  camera available on the MacBook Pro laptop computer.SCLs were recorded using non-gelled passive skin conductance electrodes attached to the upper phalanges of the index and ring fingers of the participant’s non-dominant hand. The SCL electrodes were attached to a four channel ADinstruments Powerlab (model 4/35) equipped with a GSR amplifier. SCLs were time-locked to each outcome using the FaceTime video and LabChart 7.0 analysis software.A within-subjects design was used where each participant experienced one small win (3 matching $5.00 symbols), one near-miss (players uncovered two of the three “MONTH” symbols needed to win the top prize), and four regular losses. Each participant played two scratch cards with three, 6-symbol games per card. Card “A” contained a loss, a small win, and another loss See Fig. a. Card “The rules of the scratch card games were based on those of Cash for Life©. If a player uncovered three identical symbols in one game, they won that prize. Therefore, losses consisted of six non-matching symbols; the small win consisted of three matching $5.00 symbols and three non-matching symbols; and the near-misses consisted of two matching “MONTH” symbols and four non-matching symbols. Non-matching symbols were taken from the prize structure of the original Cash for Life© scratch card game.A total of 96 cards were presented in the display case. Players chose one from the left side of the case , and one from the right side (containing 48 Card B). Players were informed that one of the 96 cards contained the grand prize (i.e. had 3 “MONTH” symbols within one of the games). The location of this top prize card was randomized at the outset of the experiment.Participants first read an information letter outlining the purposes and objectives of the study and completed a written consent form if they agreed to participate. Participants completed the CPGI using a laptop computer and Qualtrics online survey software. Following this, participants proceeded to the “lotto desk” containing the display case and scratch cards. Participants were told that they would be playing two scratch card games, and that the top prize for the game that they would be playing was $25 CAD a week for a month, which totals to a grand prize of $100 CAD. Participants were informed that there was one top prize card in the display case and that the odds of picking that card were approximately 1 in 100, as there were approximately 100 cards in the display case. The researcher then removed the trays containing the scratch cards from the display case and presented the cards to the participant. The participant was instructed to pick one card from each tray of cards.Once the participant chose their cards, the researcher went over the rules of the scratch card game. Participants were shown, on an oversized example of a scratch card, that each card has three games, and that each game contains 6 symbols (this was emphasized by an overlaid 3 by 2 grid on one of the games on the example card). The researcher then explained that to win a prize, three symbols within one game had to match. Thus, to win the top prize, three “MONTH” symbols had to be uncovered within one game. The participant was then instructed to scratch each game in the same manner that they would read a paragraph . This was done to ensure consistency of outcome delivery between participants. Participants were asked to scratch each game completely prior to moving to the next game, and to scratch the games in order  the card remained still while the participant scratched the card and (2) that the card was maximally visible for video recording of scratching. The scratching platform was angled at 30° to facilitate game play and recording.Participants were then reminded to scratch the card  one game at a time in a left-to-right fashion. After scratching their first card, the experimenter inserted the second card into the card holder of the scratching platform. Once participants completely finished scratching both cards, an occluder was placed over the card so that the participant’s view was restricted to a single game/outcome. Participants were asked to evaluate that outcome in terms of subjective arousal, valence, and levels of frustration they felt while playing that game. After rating one game/outcome, a new occluder revealed different outcome and the process was repeated until the participant had rated a loss, a win and a near miss. The orders with which they viewed and rated the outcomes were completely counterbalanced (6 possible orders). Participants were then debriefed, given their winnings, feedback about the study, and two responsible gambling brochures.In scratch card games, outcomes  are only known when the last symbol in a game is uncovered. Pre-outcome changes in SCLs over the course of uncovering the various symbols were assessed by defining a window that began when the participant scratched the first symbol in a given game, and ended when they finished scratching the last symbol in that game. Change scores were the maximum within this window (the peak), minus the value at the beginning of the window. A square root transformation was applied to this data to minimize skew within the distribution of the data , minus the value at the beginning of the window. PRPs were calculated by extracting the temporal distance (in seconds) between the last symbol in a game being uncovered, and the scratching of the first symbol in the next game.t tests .Participants’ data for each dependent variable  was first submitted to an outlier rejection procedure using a cutoff of SD = 3. The remaining data for each dependent variable were submitted to separate one-way repeated measures analyses of variances (ANOVAs), with game outcome  as the repeated measures factor. Any significant main effects were further analyzed using paired samples F = 4.92, p = .01. Fisher’s LSD post-hocs revealed that near-misses  were associated with larger SCL increases than regular losses , t(33) = 2.98, p = .005, and larger increases than small wins , t(33) = 2.09, p = .045. Wins were not significantly different from losses t(33) = 1.02, p = .32.Given that each participant experienced four losses (compared to one win and one near-miss), we averaged the SCLs for the four losses. Thus, the mean was used to represent any changes in SCLs as the symbols were uncovered during these outcomes. Shown in Fig. F = 5.50,p = .011  than near-misses , t(31) = 3.76, p = .001. Participants did not differ, however, in their SCRs following losses and wins , t(31) = 1.65, p = .11, or following wins and near-misses, t(31) = 1.55, p = .13.Given that each participant experienced four losing outcomes, these four losses were averaged to give an aggregate value of SCRs during losses. Participant’s SCRs differed depending on outcome type, F1.57, 48.862 F = 6.04,p = .014  than wins , t(29) = −2.54, p = .017, and shorter PRPs following losses  than wins, t(29) = −2.56, p = .016. Participant’s PRPs following losses and near-misses did not differ, t(29) = −.031, p = .98.Participants’ post-reinforcement pauses differed depending on outcome type, F1.24, 5.96 = 6.014 Fig. . ParticiF = 34.77, p < .001  as less arousing than near-miss outcomes , t(33) = −7.45, p < .001, and rated losing outcomes as less arousing than winning outcomes , t(31) = −7.27, p < .001. There was no significant difference between participants’ arousal ratings of near-misses and wins, t(30) = .00, p = 1.0.Participants’ ratings of subjective arousal were different depending on outcome type, 001 Fig. . ParticiF = 40.75, p < .001  as being lower in valence (more negative) than losses  fell just short of significance, t(33) = −1.95, p = .059. Participants rated near-misses as more negative than wins , t(30) = −7.48, p < .001, and losses were rated as more negative than wins, t(31) = −6.89, p < .001.Participant’s ratings of subjective valence were different depending on outcome type, 001 Fig. . ParticiM = 1.85, SD = .74) were rated as more frustrating than losing outcomes , Z = −3.77, p < .001, and more frustrating than wins , Z = −4.18, p < .001. Additionally, participants rated losses as more frustrating than wins, Z = −3.05, p = .002.After outliers were removed, all participants gave a rating of minimum frustration following the winning outcome Fig. . The lacIn this study, participants experienced three different kinds of outcomes within two scratch card games: four losses, one small win, and one near-miss. Our hypotheses were based on the frustration account of near-misses in slot machines, which theorizes that players experience a build up in anticipation when they see two jackpot symbols, but then react with frustration when the third symbol fails to complete the sequence. From an objective monetary standpoint, these outcomes are technically no different from regular losses. Nevertheless, we expected that they would produce high physiological and subjective arousal in our participants, and cause players to move on to the next available game more quickly than following a positive outcome. Furthermore, if near-misses were indeed particularly frustrating losses, they should lead participants to subjectively rate these outcomes as being negative in emotional valence, and high in frustration. In contrast, positive outcomes also produce high physiological arousal due to their rewarding properties, but (unlike near-misses) elicit a longer pause between games as the player takes time to internally celebrate their win. Additionally, if these outcomes are indeed experienced as positive, rewarding events, we would expect them to trigger high ratings of subjective arousal, positive ratings of emotional valence, and low ratings of frustration.The majority of our hypotheses were confirmed. Wins were rated as equally high in arousal as near-misses, the lowest in terms of frustration, and the highest (most positive) in emotional valence. Additionally, wins were found to elicit longer PRPs than all other outcomes. Most importantly, near-miss outcomes in scratch cards were rated as the most frustrating and the most negatively valenced of all three outcome-types. Near-misses were also rated as more subjectively arousing than losing outcomes, and equally as arousing as winning outcomes. As players uncovered the symbols in each game, there was a greater rise in SCLs as players uncovered the two “MONTH” symbols, than in either the win, or regular loss condition. Crucially, the PRPs following near-miss outcomes were shorter than those following winning outcomes, and equally as short as losing outcomes. This pattern of high arousal while uncovering the symbols, high ratings of frustration and negative valence as their hopes were dashed, and short PRPs indicating a wish to move quickly on to the next game provides converging evidence in support of the hypothesis that players respond to near-miss outcomes in scratch cards as frustrating losses, both in their retrospective subjective ratings, and also in their playing behaviours.exact opposite of what one would expect, based on research measuring physiological responses to gambling outcomes . This pattern is the Given the nonsensical nature of the post-outcome SCR results when contrasted with the extant literature and the participants own subjective reports, we put greater weight on the rise in SCLs accompanying the uncovering of the two “MONTH” symbols, and suggest that the post-outcome SCRs are an artifact of these pre-outcome changes in arousal. In sum, after eliminating from consideration the post-outcome SCRs, we are left with subjective, physiological and behavioural data that all converge to suggest that near-misses are treated very differently from other outcomes. They appear to be a particularly arousing, frustrating loss, that we know from the gambling literature impacts the urge to continue gambling . Despite the somewhat lax attitude towards them and the tendency to group them with other “soft” forms of gambling such as lotteries, scratch cards share some concerning overlap with “hard” forms of gambling such as slot machines. Foremost among these shared features is the near-miss. In both slot machines and scratch cards, near-misses trigger increases in physiological and subjective arousal, frustration, and negative valence. Thus it would not be surprising if these near-misses in scratch cards also increase desire or urge to gamble as they do in slot machines. This is a troubling prospect considering the existing availability and relatively benign reputation of these games. Further research is needed to confirm whether scratch card near-misses do indeed increase the urge to gamble, and whether such urges translate to spending more money than intended on purchasing further scratch cards. The results of this study, however, suggest that perhaps it is time to reconceptualize scratch card games as a “harder” form of gambling (Griffiths and Wood Though not historically an area of extensive focus in gambling research, lottery games, in particular scratch cards and other instant games, are an important avenue of exploration. With youth accessing these products at alarming rates and their clear surface similarities to slot machines and other gambling forms, understanding how scratch cards emotionally, physically, and behaviourally affect the player is paramount. To our knowledge, this study is the first investigation of the physiological, behavioural, and subjective effects of experiencing varying outcomes on a scratch card game. Importantly, this is also the first study to explore the effects of near-miss outcomes in these games, despite the fact that near-misses on slots are known to trigger large physiological responses in the player and increase player’s urge to gamble (Clark et al. Future directions for this line of research includes utilizing other physiological measures to understand the physical effects that these games have on the player. Specifically, heart rate deceleration has been used as an index of arousal (Dixon et al.