Background: Surgical procedures require the collaboration of medical personnel with multiple skill sets who have different levels of training. Someone new to surgical procedures, such as a medical student, faces a steep learning curve. Studies have shown that video-assisted learning is associated with improved learning of surgical procedures.Methods: During their surgical rotation orientation, third-year medical students were invited via email to participate in a learning study featuring a cardiopulmonary bypass video. Study participants took a pretest, reviewed the locally developed video, and took a posttest and an attitudinal questionnaire after viewing the video.Results: A convenience sample of 31 third-year medical students participated in the study. Overall knowledge scores improved from pretest to posttest . In the posttest attitudinal questionnaire, students reported that they preferred video-assisted learning to reading written protocols (90.3% strongly agree/agree) and that they were more knowledgeable about the function of the cardiopulmonary bypass machine (80.7% strongly agree/agree) after viewing the video. Students also reported that the video would be useful during their surgical clerkships (90.4% strongly agree/agree).Conclusion: Video-assisted learning was associated with comprehension of the material immediately after viewing the video, and medical students considered it to be appropriate and useful. This educational video may benefit other learners who are entering the cardiopulmonary bypass operating room for the first time. Entering the operating room (OR) for the first time can be overwhelming. To help prepare students and new staff for the experience, an educational video was produced at Ochsner Health to introduce cardiopulmonary bypass surgery and familiarize learners with the OR. The video introduction is appropriate for any personnel new to the OR, such as medical technologists, nursing students, medical students, and residents.1 Surgical teams may struggle to teach medical students in the short time frame of an operation; Sweeney suggests pairing traditional lectures with new methods of active learning such as medical simulation and video review when appropriate.2Complex surgical procedures such as cardiothoracic surgeries require all personnel in the OR to have the awareness and requisite surgical knowledge to engage and to decrease the potential for human error.4 A 2016 study showed that instructional videos of interventional breast procedures led to efficient learning and enhanced comprehension among radiology residents.5 In response to a survey conducted by Hayden et al, general surgery residents in cardiac and thoracic services reported the need for easily accessible resources about surgical procedures, and that response drove the development of a surgical educational video.6 Video-assisted debriefing has been shown to improve learner experience, attitudes, and performance compared to verbal debriefing.7Many of today's learners prefer digital and nontraditional educational methods. Studies published in 2013 and 2017 demonstrated that instructional videos provided better preparation for procedures among residents than traditional methods did, especially for procedures that were new to them.The primary aims of this study were to determine if a video could improve medical students’ knowledge and understanding of cardiopulmonary bypass surgery and whether the video would be acceptable to medical students.This study was reviewed and approved as exempt by the Ochsner Clinic Foundation Institutional Review Board.One of the authors (P.E.P.) developed the video  prior toBecause of positive responses from viewers and faculty members, a project to test the effectiveness of the video and disseminate it outside Ochsner Health was initiated. Two authors (M.T.T. and G.D.D.) collaborated to develop a 9-question pretest/posttest  to exploDuring their surgical rotation orientation, 54 third-year medical students from The University of Queensland-Ochsner Clinical School were invited via email to participate in this study. Volunteer participants completed the pretest, viewed the video, and completed the posttest and questionnaire.Responses were collected and analyzed. Chi-square test was used to compare the percent correct answers before and after viewing the video. The 5-point Likert scale responses were collapsed into 3 categories  for ease of analysis. Chi-square test was used to compare agree/strongly agree responses to disagree/strongly disagree responses.P<0.001).Thirty-one third-year medical students (57.4% of invited students) completed all 3 components of the assignment: pretest, video viewing, and completion of the posttest and questionnaire. As shown in In the questionnaire administered after the posttest, students reported that the video content was appropriate and useful. They reported that they preferred watching the video to reading a protocol and that the video was well prepared. Students’ confidence in their knowledge of the roles of the perfusionist and circulator nurse and the function of the bypass machine increased, but they did not report increased confidence in reciting the steps of the procedure or in being ready to assist in the procedure .7 and the use of video was effective in this study. In the questionnaire responses, almost all learners reported that they understood the roles in the cardiothoracic OR after viewing the video and affirmed the appropriateness and usefulness of the video. However, students did not report high confidence regarding assisting in or reciting the steps of the procedure after viewing the video.Our results aligned with the expectation that student scores on a knowledge test would increase after viewing the video. Some learners prefer video-assisted learning,High confidence would have been a surprising result, as cardiopulmonary bypass is among the most complex surgeries in medicine. Many years of postgraduate training are required to achieve competence. A video alone cannot be expected to increase confidence significantly; only repeated practice over time should have that outcome.7 particularly for learners who prefer videos and for material suited for video-assisted learning, such as procedures. Comparisons of video-assisted learning and other forms of learning, such as didactics, paper cases, and simulation, have not consistently shown that students prefer one form to another.8Video-assisted learning has a place in medical education,Our investigation has several limitations. While student knowledge improved, we did not have a comparison group to show if the improvement in the video group was better than the improvement demonstrated by students who reviewed a paper case or read the information in an article. A convenience sample may not be representative of the class as a whole and may contain students with more or less confidence in surgical procedures. Also, posttest results can be influenced by pretest questions. After taking a pretest, students may view the video in search of answers to the questions. To further assess learning outcomes, we may consider incorporating questions that test students’ ability to apply, recall, and synthesize information.A future direction for study is to include a comparison group with learning presented in a different format, such as a paper case, to establish whether the video results in better knowledge outcomes. We could also attempt to recruit an entire class of students to reduce the selection bias inherent in a convenience sample. This educational video has been added to the surgical orientation curriculum.Entering the OR for the first time can be a daunting experience, particularly for medical students. The preclinical years of medical school education often do not prepare medical students to face the kinesthetic experiences and fast pace of the OR. Studies have shown that video-assisted learning has become a popular educational modality, and our video was effective in increasing students’ knowledge of cardiopulmonary bypass surgery.


Regarding the paper “Weight gain among treatment‐naïve persons with HIV starting integrase inhibitors compared to non‐nucleoside reverse transcriptase inhibitors or protease inhibitors in a large observational cohort in the United States and Canada” by Kassem Bourgi, Cathy A Jenkins, Peter F Rebeiro, Frank Palella, Richard D Moore, Keri N Altoff, John Gill, Charles S Rabkin, Stephen J Gange, Michael A Horberg, Joseph Margolick, Jun Li, Cherise Wong, Amanda Willig, Viviane D Lima, Heidi Crane, Jennifer Thorne, Michael Silverberg, Gregory Kirk, William C Mathews, Timothy R Sterling, Jordan Lake and, John R Koethe for the North American AIDS Cohort Collaboration on Research and Design (NA‐ACCORD)Journal of the International AIDS Society, Citation: Journal of the International AIDS Society 2020, 23: 25484. https://doi.org/10.1002/jia2.25484Published in the The author name, “Keri N Altoff” was misspelt and should have been corrected to “Keri N Althoff”.Bryan Shepherd was omitted and should have been added to the list of authors.The authors noticed the following errors in the author byline and should have been corrected.The author byline should have read:1,2, Cathy A. Jenkins1, Peter F. Rebeiro1, Bryan E. Shepherd1, Frank Palella3, Richard D. Moore4, Keri N. Althoff4, John Gill5, Charles S. Rabkin6, Stephen J. Gange4, Michael A. Horberg7, Joseph Margolick4, Jun Li8, Cherise Wong4, Amanda Willig9, Viviane D. Lima10, Heidi Crane11, Jennifer Thorne4, Michael J. Silverberg12, Gregory Kirk4, William Christopher Mathews13, Timothy R. Sterling1, Jordan Lake14 and John R. Koethe1,15,§ for the North American AIDS Cohort Collaboration on Research and Design (NA‐ACCORD)Kassem Bourgi1Vanderbilt University Medical Center, Nashville, Tennessee, USA; 2Indiana University School of Medicine, Indianapolis, Indiana, USA; 3Northwestern University Feinberg School of Medicine, Chicago, IL, USA; 4Johns Hopkins University, Baltimore, Maryland, USA; 5University of Calgary, Calgary, Alberta, Canada; 6National Cancer Institute, Bethesda, Maryland, USA; 7Mid‐Atlantic Permanente Research Institute, Kaiser Permanente Mid‐Atlantic States, Rockville, Maryland, USA; 8Centers for Disease Control and Prevention, Atlanta, Georgia, USA; 9University of Alabama at Birmingham, Birmingham, Alabama, USA; 10University of British Columbia, Vancouver, British Columbia, Canada; 11University of Washington, Seattle, Washington, USA; 12Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA; 13University of California San Diego, San Diego, California, USA; 14University of Texas Health Science Center at Houston, Houston, Texas, USA; 15Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USAThis article has been corrected online.


Markers of renal damage were increased as well after the end of the saturation dive . These results could ameliorate commercial or military diving protocols or improve the understanding of symptoms caused by oxygen level elevation.Saturation diving allows divers to reduce the risk of decompression sickness while working at depth for prolonged periods but may increase reactive oxygen species (ROS) production. Such modifications can affect endothelial function by exacerbating oxidative stress. This study investigated the effects of saturation diving on oxidative stress damage. Redox status was evaluated through: ROS production; total antioxidant capacity (TAC); nitric oxide metabolites (NOx); nitrotyrosine (3-NT); and lipid peroxidation (8-iso-PGF2α) assessment. Creatinine and neopterin were analyzed as markers of renal function and damage. Measurements were performed on saliva and urine samples obtained at four time points: pre; deep; post; and 24 h post. Four divers were included in the study. After the saturation dive (post), significant ( These subjects also spend a long time in isolation, alternating strenuous shift work with prolonged relative inactivity [Saturation diving, also known as “Commercial Offshore” or “Diving Underwater Habitat”, is a prolonged diving technique that brings gas concentrations in tissues into equilibrium with environmental gases . These dactivity .2 is converted to reactive oxygen species (ROS), and hyperoxia increases this amount [2 are known to induce inflammation [Under normal physiological conditions, approximately 1.2% of inspired Os amount . As suggs amount ,9,10 chaammation ,12 and iammation ,14.2 transport and increased endogenous antioxidant activity after saturation diving.Little is known about the balance between pro-oxidant effects and antioxidant responses related to saturation diving. Antioxidant defenses are known to increase when the production of ROS is enhanced ,15,16. A2 free radical produced as part of normal physiology is nitric oxide (NO). Hyperoxia increases the activity of all three NO Synthase isoforms  via several mechanisms [Another Ochanisms ,19. NO sThis study aimed to investigate the effects of saturation diving on oxidative stress for the first time. In particular, we planned to determine ROS production and total antioxidant capacity (TAC) via electron paramagnetic resonance (EPR), the only technique that enables the direct detection of free radicals ,21,22, uThis study involved four professional  divers working in the Southern Adriatic Sea, whose anthropometric and physiological parameters are reported in The study was conducted following the Helsinki Declaration and was approved by the Ethical Committee of Università degli Studi di Milano, Italy (Aut. n° 37/17). All the volunteers signed an informed consent. Monitoring sessions were conducted onboard the main ship between 20 December 2019 and 21 January 2020.2 was kept between 410 and 420 mbar, increasing to 500 mbar at the end of the decompression. The hyperbaric environment had a controlled humidity of 50–70% and a temperature of 29–31 °C. Additionally, carbon dioxide was monitored continuously to ensure a maximum level of 5000 ppm. Divers alternated 8–10 h of underwater work with 12 h of rest in the chamber hosted onboard. While working at depth, the PO2 of the lockout gas supplied to the divers was set between 0.6 and 0.9 atm.In Antioxidant supplements see  were admSamples of saliva and urine were obtained at four time points before, during, and after a saturation dive: before (pre) on 20 December; at maximum depth on 10 January (deep); immediately after the end on 20 January (post); and 24 h after the end on 21 January (24 h post).Saliva samples were collected to determine levels of ROS and TAC. Nitrite/nitrate (NOx), 3-nitrotyrosine (3-NT), lipid peroxidation (8-isoprostane), IL-6, neopterin, and creatinine concentrations were measured on urine samples. Approximately 1 mL of saliva was obtained by Salivette devices . The subjects were instructed on the correct use and to refrain from drinking, eating, smoking, brushing their teeth, and using mouthwash in the 30 min before salivary collection. Samples were spun down, aliquoted, and stored.Urine samples were collected by voluntary voiding in a sterile container and were stored in multiple aliquots at −20 °C until assayed and thawed only once before analysis. Electron Paramagnetic Resonance spectroscopy X-band (9.3 GHz)  was used to assess ROS production and TAC. Samples were analyzed in triplicate. A 37 °C unit by Temperature and Gas Controller ‘‘Bio III’’ , interfaced with the E-Scan, was preserved. ROS production and TAC assessment methods were previously described ,24,25,26NOx concentrations were assessed in urine via a colorimetric method based on the Griess reaction , using a3-NT and NO levels have a direct relationship. The assay kit adopted  used Competitive-ELISA as the assessment method. The analysis was carried out in accordance with the manufacturer’s instructions. The concentration of 3-NT in urine was measured spectrophotometrically at a wavelength of 450 nm by comparing the samples’ OD  to a standard curve.Lipid peroxidation was assessed in urine by competitive immunoassay of 8-isoprostane concentration (8-iso-PGF2 α) . Samples were read in duplicate at a wavelength of 512 nm. This method has been previously described .IL-6 levels were determined using the ELISA assay kit , based on the double-antibody “sandwich” technique in accordance with the manufacturer’s instruction.All the above samples and standards were read by a microplate reader spectrophotometer . The determinations were assessed in duplicate, and the inter-assay coefficient of variation was in the range indicated by the manufacturer.Urinary creatinine and neopterin concentrations were measured by isocratic high-pressure liquid chromatography (HPLC). Methods have been previously described ,14.p < 0.05 was considered statistically significant. Change ∆% estimation /pre value) × 100) is also reported in the text.Data are presented as mean ± standard deviation (SD). Statistical analysis was performed using the GraphPad Prism package . After the Shapiro–Wilk normality test, statistical analyses were performed using non-parametric tests. Data were analyzed with the Friedman non-parametric test for multiple comparisons and Dunn’s post-hoc to determine differences among conditions. No significant differences were observed in anthropometric and physiological parameters between pre and post 30 days of saturation diving. Only a small percentage reduction in weight (−4%), measures of: the waist (−2%) and hips ( anatomic part of the body) (−1.5%), BMI (−4%), and an increase in diastolic blood pressure (DBP) (+13%) can be observed see .−1) (−1 creatinine) (−1) (Significant increases at post saturation dive of ROS production rate (0.12 ± 0.03 vs. 0.36 ± 0.06 µmol·min−1) A, antiox−1) B, 8–isopatinine) C, NOx (2atinine) E, and 3-ne) (−1) F were ob−1 creatinine) (−1), and TAC (1.88 ± 0.03 vs. 1.94 ± 0.06 mM) at 24 h post saturation dive were measured  C. Finallmeasured A,B too.−1) and neopterin/creatinine (73.3 ± 27.9 vs. 174.3 ± 20.53 μmol·mol−1 creatinine) levels, respectively, at post-saturation dive. Finally, a significant increase in IL-6 was found at post (1.77 ± 0.84 vs. 2.79 ± 1.12 pg·mL−1) (The time of course in pg·mL−1) D.In commercial and military saturation diving, workers can live in an underwater habitat or a surface complex. In the latter, divers rest in the living chamber and are transferred to a submersible decompression chamber (the “diving bell”) when they need to reach working depth . Spendin2 transport and increased endogenous antioxidant activity after saturation diving. During prolonged exposure to a confined, hyperbaric, hyperoxic environment, antioxidant supplementation is recommended for saturation divers to reduce oxidized molecules [The redox status of human cells is finely regulated, with antioxidant systems always balancing ROS generated by normal metabolism. ROS are usually associated with damages and negative consequences exerted on cells but are also involved in several protective mechanisms, such as immune defense, antibacterial action, vascular tone regulation, and signal transduction . Moreoveolecules . Howeverolecules .The membrane lipid peroxidation process is one of the earliest events in oxidative cellular damage and is associated with fine structure disturbance and subsequent function loss. In the present study, lipid peroxidation markers were increased at deep and post-saturation diving, probably resulting from compression rather than hyperoxia, as previously reported . These r2 (hyperoxia/hypoxia) can increase ROS accumulation in the whole body [As widely reported, modifications in POole body ,34,35,36ole body  and pulmole body . Howeverole body .Indeed, in the present study, the level of 3-NT, the product of tyrosine nitration mediated by reactive nitrogen species such as peroxynitrite anion increased. Otherwise, in our experimental set-up, the growth of circulating ROS, NOx, and 3-NT levels is probably due instead to the prolonged hyperoxic exposure than to exercise. In fact, in a previous study performed by the authors , the incThe levels of neopterin and creatinine can increase during systemic oxidative stress ,14,40,41In the present study, the increase of these biochemical parameters’ concentration was observed immediately post-saturation diving and was associated with a rise in ROS production. Even though this study did not evaluate the chronic or long-term effects of saturation diving on kidney function, the four divers manifested a temporary “impairment of renal function” as a likely physiological or adaptive response to hyperoxia. Hyperoxic acclimatization in saturation is also in line with reports of transient symptoms of hypoxia; therefore, management of oxidative stress is essential for health preservation. The body’s endogenous redox systems generally provide this in normoxia, but diving challenges the physiological balance by inducing ROS production in excess. As reported by Brubakk et al.  and confAdditionally, we found an elevated concentration of IL-6 in post-dive. IL-6 is the first cytokine released into the circulation , reflectA statistically significant difference was found in post diving as previously reported .It is worth noting the reliability of the micro-invasive methods adopted in this study, reflecting the oxidative/inflammation systemic response. Such techniques are feasible in paramount situations such as the “deep environments” and, at the same time, allow easier recruitment of subjects for scientific tests.These results could help to improve commercial, police or military diving, scientific exploration, or even help to prepare astronauts for future space exploration. Therefore, the results can help to understand the mechanism generating distress symptoms caused by elevating of the oxygen levels or other phenomena.Diving deeper into the water is only for professional saturation divers, and it is a career which is very hard and dangerous. Therefore, there are only a few professionally habilitated saturation divers in the world. It is clear, therefore, that the study suffers from some limitations. Indubitably, the too small number of investigated divers and the high variability among subjects is a limitation, but also the lack of blood sampling during the study, which was a decision made so as to be as little invasive as possible.Be that as it may, our strength consists in assessing, for the first time, ROS production and antioxidant capacity by EPR, nitric oxide level, and renal function before, during, and after saturation diving, with non-invasive methods.The main limitation of our study is the small sample. We were forced to include only four subjects due to the scarcity of saturation divers available to take part in the study, and due to technical and logistics constraints. Therefore, results have to be interpreted carefully, and the conclusions cannot be extrapolated to every saturation diver. This being a pilot study, we plan to set international collaborations in the future to increase the number of participants. Nevertheless, this is the first study to assess ROS production, antioxidant capacity, and nitric oxide levels in saturation divers in a real environment.Saturation diving is shown to induce an increase in ROS and NO metabolites. Moreover, in this experiment, transient damage in renal function was noted. Future studies are required to investigate the biochemical processes and the clinical correlations consequent to chronic exposure to high pressure.


The COVID-19 pandemic has required drastic safety measures to control virus spread, including an extended self-isolation period. Stressful situations increase alcohol craving and consumption in alcohol use disorder (AUD) and non-AUD drinkers. Thus, we assessed how COVID-19 related stress may have affected drinking behaviours in the general population.We developed an online cross-sectional survey, Habit Tracker (HabiT), which measured changes in drinking behaviours before and during COVID-19 quarantine. We also assessed psychiatric factors such as anxiety, depression  and impulsivity . Lastly, we related drinking behaviours to COVID-19 specific stress factors.HabiT was released internationally, with individuals from 83 countries participating.Participants were included if they were 18 years of age or older and confirmed they were proficient in English. The survey was completed by 2873 adults with 1346 usable data (46.9% accurately completed).Primary outcome measures were change in amount and severity of drinking behaviours before and during quarantine, and current drinking severity during quarantine.Although drinking behaviours decreased overall during quarantine, 36% reported an increase in alcohol use. Those who increased alcohol use during quarantine were older individuals , essential workers , individuals with children , those with a personal relationship with someone severely ill from COVID-19  and those with higher depression , anxiety , and positive urgency impulsivity . Furthermore, country-level subsample analyses indicated that drinking amount  increased in the UK during quarantine.Our findings highlight a role for identifying those vulnerable for alcohol misuse during periods of self-isolation and underscore the theoretical mechanism of negative emotionality underlying drinking behaviours driven by stress. Limitations include a large degree of study dropout (n=1515). Future studies should assess the long-term effects of isolation on drinking behaviours. The Habit Tracker (HabiT) study sampled drinking behaviours of a large, diverse population during the COVID-19 pandemic.Changes in drinking behaviours were assessed against specific COVID-19 related stress factors.Due to the length of the survey (8–10 min), we observed a large degree of study dropout.Subjects were within varying phases of lockdown during the time of testing.The prevalence of diagnosed alcohol use disorder drinkers sampled was low, likely related to sampling issues or under-reporting.The COVID-19 pandemic has necessitated drastic safety measures to control the virus spread. These measures included an extended self-isolation period in which individuals were permitted to leave their places of residence only to obtain amenities  or engage in essential work. Individuals were not permitted face-to-face contact with anyone who did not reside within their immediate households. In the UK, these measures were instituted nationally on 23 March 2020, with a gradual lifting of restrictions on 10 May 2020, ending on 4 July 2020 with locality-specific intermittent reinstatement of these measures. Although a necessary precautionary measure to mitigate the devastating effects of COVID-19 on public health, evidence indicates that protracted periods of self-isolation, especially in the context of stress, may be related to acute and prolonged negative mental health consequences, particularly in individuals already struggling with psychiatric disorders.1Indeed, current clinical reports from individuals in treatment for substance abuse disorder indicate that the stress produced by COVID-19 social isolation measures have triggered greater and more frequent drug or alcohol cravings, subsequently leading to relapse.Increases in alcohol craving and consumption after stress exposure also occur in those without AUD. An increase in alcohol consumption is often used as a coping strategy for both chronic and specific stressful life events in both AUD and non-AUD drinkers.3 16Thus, in response to these exceptional circumstances, we aimed to assess how social isolation measures in the midst of the COVID-19 pandemic may have affected drinking behaviours in the general adult population. We developed an international survey, entitled Habit Tracker (HabiT), which evaluated drinking severity before  and during the COVID-19 quarantine period. We hypothesised that changes in amount of alcohol consumption and severity of drinking behaviours may be related to specific COVID-19 related stress factors, as well as demographic and psychiatric factors. Furthermore, we investigated if COVID-19 related stress factors influenced changes in drinking amount, drinking severity, depression, and anxiety before and during quarantine.The HabiT survey was a questionnaire that sought to assess the effects of isolation on alcohol, smoking, and internet use. The effects on alcohol use are reported here. Subjects were included if they were 18 years of age or older and confirmed they were proficient in reading and understanding English. HabiT was advertised by University of Cambridge news page on 11 May 2020, a day before its international release. For the next several days, the survey was disseminated by news agencies throughout the UK  as well as throughout various University of Cambridge colleges. Furthermore, the survey was posted and shared on personal and public social media sites . All subjects gave informed consent and were not financially compensated for their participation, although informed that—on survey completion–they would be provided results of the study through request. The data collected was fully anonymised. The survey was created using Qualtrics  survey-building platform. Developed iteratively within-lab and among coauthors to insure brevity and consistency, the average time to complete the survey was approximately 8–10 min, and all subjects could participate on either a computer or smartphone device.We did not involve patients or the public in the research design, reporting, or survey dissemination strategies of this study.The demographic information collected were as follows: age, gender, socioeconomic status, intimate relationship status, country and city of residence, and any previous or current diagnosis of a psychiatric or neurological disorder.Every major section of the survey contained at least one question that served as an attentional check to ensure subjects were correctly reading and answering survey questions to the best of their ability. The attentional checks were structured to mirror the Likert scaling of each section .We first asked subjects if they drank alcohol. If the answer was negative, they proceeded to the next set of questions. If the answer was positive, we assessed the change in the amount and severity of alcohol use as well as the current severity of alcohol use. We asked subjects to report the following behaviours within a typical week in November  and within the last week : (1) the number of units of alcohol consumed within the last week with examples for the number of units for differing types of alcohol and sizes provided; and (2) the change in severity using a timescale adaptation of the first three questions of the Alcohol Use Disorders Identification Test, which assessed the amount and frequency of alcohol consumption (AUDIT-C).We assessed 10 factors that may contribute to COVID-19 related stress using the following questions:Have you been deemed an ‘essential worker’ by your government?Do you work for healthcare services specifically with individuals who have contracted COVID-19? (Subquestion of question 1)Has your employment situation changed due to the COVID-19 crisis?Has anyone you know personally contracted or have shown symptoms characteristic of COVID-19?Has anyone you know personally become severely ill or died due to contracting COVID-19?Are you isolated alone?Do you have children?If you have children, are you their only caretaker? (Subquestion of question 7).If you are currently in isolation with others, how would you describe the quality of your relations?How often do you currently go outdoors ?Depression and anxiety symptomatology were measured using The Hospital Anxiety and Depression Scale (HADS), a brief, validated four-item questionnaire.Statistical analyses were performed using MATLAB (V.2020a). All subjects who answered the attentional checks incorrectly (n=12), reported highly improbable answers regarding the units of alcohol they consumed weekly , did not report their gender, or did not complete the psychiatric questionnaires were excluded from further analysis; leaving a total of 1346 subjects. Drinking severity scores of the sample were non-normally distributed , thus non-parametric tests were used.We used Mann-Whitney U tests to compare weekly alcohol unit consumption and alcohol severity before and during quarantine in the full group. Then, we divided subjects into three groups, those who during quarantine either increased, decreased, or did not change their alcohol consumption, and performed a Kruskal-Wallis H-test to assess the relative drinking amount to severity indices of these groups.We then assessed which COVID-19 related stress factors were associated with changes in either amount , change in severity (AUDIT-C), current severity (full AUDIT), or current depression and anxiety (HADS) using the following tests: (1) Mann-Whitney U tests to compare negative versus positive responses to the COVID-19 stress factors (MW), (2) multivariate analysis of covariance (MANCOVA)On an exploratory basis, we then used Spearman’s partial correlations to compare the drinking severity indices of subjects who completed the timescale-adapted full AUDIT with SUPPS-P and HADS scores to relate drinking severity of the overall sample to psychiatric measures. Lastly, in order to assess possible directional relationships in changes in the severity of drinking behaviours to depression, anxiety, and impulsivity, we performed Spearman’s partial correlations with the psychiatric questionnaires among the three aforementioned groups . For both correlational analyses, we used FDR correction (p<0.05) for multiple comparisons.A total of 2873 subjects participated (data collection: 12 May 2020–28 May 2020) of which 1346 had usable data based on defined criteria . Of these subjects, 859 (63.8%) reported that they drink alcohol . Of the 1346 subjects, the average age was 28.92±10.45 years (95% CI 28.2 to 29.53) (range=18–90) with more males  from 85 different countries of residence, with the majority from the UK (n=434) and the USA (n=355), followed by Canada (n=64) and Germany (n=63). Marital status was as follows: single: n=785; married or committed: n=571; divorced or separated: n=33; widowed: n=4. Socioeconomic status  was as follows: <19.9k: n=285; 20–39.9 k: n=273; 20–39.9 k: n=244; 40–69.9 k: n=241; 70–99.9 k: n=141;>100k: n=203; and 232 subjects did not report their incomes. Current psychiatric or neurological diagnoses were as follows: no diagnosis: n=1192; depression: n=60; anxiety: n=38; post-traumatic stress disorder: n=5; and comorbid depression and anxiety: n=46.2=72.86, p=0.001; Of the total sample, the change in problem drinking severity (AUDIT-C) was 0.89±1.43 (95% CI 0.81 to 0.96) (range: 0–8) and the mean change in the amount consumed was 5.62±9.55 units per week (95% CI 3.16 to 4.02) (range: 0–120). The current problem drinking severity (full AUDIT) was 3.14±4.47 (95% CI 2.9 to 3.37) (range: 0–32), with 557 subjects included that do not consume alcohol. Of the subjects who reported they consume alcohol (n=859), the change in severity from prequarantine to quarantine was a decrease of 1.53±1.6 (95% CI 5.01 to 5.64), range 0–8 (U=2.65 (95% CI 0 to 0.21) p=0.008). The units of alcohol consumed per week was significantly decreased during the quarantine period (8.03±14.22 units (7.11–8.94) range=1–120) compared with November (8.32±11.92 units (95% CI 7.47 to 9.02) range=0–150), U=−2.29 (95% CI 0.0 to 0.0) p=0.02 . However10.1136/bmjopen-2020-044276.supp1Supplementary datas=0.2 (95% CI 0.04 to 0.1) p<0.0001) and gender with males (6.44±10.8 units (95% CI 5.63 to 7.35) range: 0–120) showing an increased change in drinking amount relative to females (3.81±5.18 (95% CI 3.08 to 4.32) range: 0–38), or other genders (1.32±1.65 (95% CI 0.18 to 2.24) range: 0–5) . Changes in drinking severity were also related to both age and gender, with older individuals (rs=0.2 (95% CI 0.01 to 0.02) p<0.0001) and males (1.68±1.74 (95% CI 1.55 to 1.83) range: 0–8) demonstrating greater changes in their drinking severity than females (1.16±1.12 (95% CI 1.02 to 1.3) range: 0–8), and others (1.36±1.29 (95% CI 0.54 to 2.18) range: 0–3) (H=6.02 (95% CI −0.81 to −0.22) p=0.05). , p=0.05) and greater severity of current drinking (F=7.01 (95% CI −3.9 to −0.6) p=0.007) when controlled for all variables. Being the only caretaker for children was also associated with greater change in drinking severity (U=2.62 (95% CI −2.7 to −0.9) p=0.009) and greater change of amount consumed (U=2.67 (95% CI −4.5 to −0.8) p=0.007) but was no longer significant when controlling for age and gender.s=0.12 (95% CI 0.34 to 0.79) p=0.004), anxiety (rs=0.12 (95% CI 0.3 to 0.74) p=0.027) and positive urgency impulsivity (rs=0.12 (95% CI 0.14 to 0.34) p=0.004), controlled for age and gender. To assess potential directional relationships between current drinking severity during quarantine and psychiatric measures, we correlated depression, anxiety, and impulsivity with the three drinking groups . Drinking severity scores in the decreased and no change groups were not significantly correlated with any of the psychiatric measures of interest. However, drinking severity of those who increased their units consumed during the quarantine period were related to depression (rs=0.30 (95% CI 0.67 to 1.45) p<0.0001), anxiety (rs=0.23 (95% CI 0.61 to 1.5) p=0.0002), and positive urgency (rs=0.17 (95% CI 0.16 to 0.72) p=0.009)  completed the current drinking severity index . The severity of drinking behaviours was positively related to depression (rp=0.009) .We show an overall decrease in amounts and severity of problem alcohol use from prequarantine to the quarantine period. Critically, however, three different subpopulations were identified, with most either increasing or decreasing use as compared with remaining unchanged in their alcohol use behaviours. Greater drinking was associated with demographic factors including age, COVID-19 stress-related factors, and psychiatric factors such as depression, anxiety, and the impulsivity subscale of positive urgency. Increases in drinking were also region-specific; with UK residents demonstrating an upswing in weekly amount of alcohol consumed during quarantine. Our findings underscore the theoretical mechanism of negative emotionality underlying drinking behaviours driven by stress, depression and, anxiety.An overall decrease in alcohol consumption and problematic use may have multiple, potential aetiologies. Stringent lockdown may be associated with a decrease in the presence or availability of alcoholic beverages within the immediate household given limitations in access, a decrease in exposure to alcohol cues that may trigger urges, or the preference to consume alcohol within social contexts. More subjects reported either decreasing or increasing the frequency of their alcohol intake compared to remaining unchanged, consistent with previous reports of a greater tendency towards extremes in individual drinking patterns when faced with either acute or chronic life stressors.15Older individuals showed a greater increase in drinking behaviours during lockdown and current severity of problem drinking, consistent with demographic factors known to be associated with alcohol misuse. Whether one increases their drinking after experiencing acute or chronic life stress is age dependent, which may reflect a function of previous alcohol experience.25COVID-19 specific stress factors appear to influence drinking behaviours controlling for other confounding variables. Being deemed an essential worker and having children was associated with a greater increase in drinking behaviours during quarantine. Importantly, although having children was associated with an increase in alcohol use, depression and anxiety scores were lower than in those without children. This suggests the additional burden of childcare and home schooling contributed to the tendency towards drinking- possibly in the context of stress relief- and was not mediated by greater depression or anxiety symptoms. The presence of children may also be protective against depressive and anxiety symptoms during lockdown. Having children may mitigate against loneliness that has been highlighted as a major issue during the isolation of lockdown.As expected, having a personal relationship with someone who had become severely ill or died due to COVID-19 was associated with a greater increase in severity of problem drinking behaviours. Going outdoors more frequently for work, exercise, or essential duties during lockdown was similarly associated with greater severity of alcohol use, as well as depressive and anxiety symptoms. The reasons behind the need to go outdoors complicate the interpretation, as it might be confounded by being an essential worker, but would also allow for greater access to the purchase of alcohol. Living with others but having a poor quality of relationship was unexpectedly associated with lower drinking severity but with greater depressive and anxiety symptoms. Living alone was not associated with any changes in drinking behaviours but was associated with greater depressive symptomatology. These findings might support the role of drinking in the context of social interactions and further highlight the importance of socialisation during lockdown, the role of loneliness, and its impact on mental health.27We further observed a relationship between the current severity of drinking behaviours and psychiatric symptoms such as depression, anxiety, and positive urgency. These relationships were driven particularly by the group that increased their drinking during quarantine. That both negative and positive emotionality factors are associated with increased drinking behaviours is in keeping with the multiple paths towards problematic alcohol use. The effects of depression and anxiety on alcohol consumption in both AUD and non-AUD drinkers are well documented,33acute effects of COVID-19 isolation measures on changes in drinking behaviours in comparison to the prequarantine period. Hence, follow-up studies should be employed during the immediate postquarantine period to investigate the possible protracted effects of COVID-19 isolation on drinking behaviours. Furthermore, whether the sampling adequately reflects the population distribution in the form of sampling bias may be an issue with online questionnaires and may under-represent those who do not have smartphones or access to the internet,This study is not without limitations. HabiT is a cross-sectional, retrospective survey and hence potentially limited by recall and misclassification biases as well as lack of longitudinal follow-up. Because retrospective reporting involves issues with memory, possible Dunning-Kruger effects, and selection bias, the reader should be cautious in drawing causal interpretations from the current data. Because the aim of the HabiT study was to investigate changes in amount and severity of drinking behaviour in a large, wider population, we issued the survey internationally and during a later period of enforced isolation. Thus, the possibility cannot be overlooked that subjects were within varying phases of lockdown characterised by differential restrictions during the time of testing, which may have influenced our current results. Future studies may consider data analysis by country, level of lockdown, or amount and severity of localised COVID-19 cases. Also, approximately half of the individuals who began the survey did not complete it. This may be due to the length of the survey . Prospective studies using an online survey design should further condense questionnaires and/or offer subjects monetary incentives obtained on survey completion in order to attenuate dropout and non-response bias. The current HabiT survey only assessed the Although alcohol drinking behaviours appeared to decrease overall during lockdown, we emphasise that specific groups may be at higher risk for developing problematic alcohol use. In particular, factors associated with an increase in alcohol use include older individuals, essential workers, parents with children, those with a personal relationship with someone severely ill from COVID-19, and those with higher depression, anxiety, or positive urgency impulsivity. Furthermore, unlike residents from the USA and Canada, those in the UK increased their weekly alcohol intake during the quarantine period. We emphasise that those with a previous history of alcohol misuse or a family history of AUD were not the specific focus of this study, and may represent a high risk group that requires further investigation. Alcohol can be used in brief, moderate amounts in a healthy, non-pathological manner related to socialisation and stress relief. However, a subgroup of these individuals may still be at higher risk for longer term issues with alcohol misuse. The lockdown resulted in a unique set of stressors that in some cases may persist  and might again re-emerge with the imposition of localised lockdowns or further lockdowns in the context of a second or third wave. Further studies on the longitudinal impact and persistence of these behaviours are critical. Our findings highlight a need for identifying those at greater risk for alcohol misuse to aim for greater support services and proactively target mental health issues associated with problem drinking behaviours such as depression or anxiety.


Previous evidence indicates significant associations between depressive disorders and alcohol use disorder (AUD) and their strong links with social conditions. This study aims to investigate the association between major depressive episode (MDE) and AUD across various socio-economic groups.> 20 years from the general population. The Alcohol Use Disorder Identification Test was used to classify respondents into non-problem drinking (score 0–7), hazardous drinking (score 8–15), and harmful-dependent drinking (score 16–40). MDE was identified using questions based on the DSM-IV. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated using multinomial logistic regression to determine the strength of associations between MDE as a predictor and AUD as an outcome variable across different socio-economic levels.We analysed data from the 2014 Thai National Health Examination Survey containing a random sample of 13,177 adults aged The prevalence of MDE, hazardous, and harmful-dependent drinking was 2.5, 10.3, and 1.9%, respectively. The association between MDE and AUD was modified by wealth index, education level and area of residence. AORs for the association between MDE and harmful-dependent drinking were high among those in the highest  and lowest  levels of wealth index but not significant among those in the middle level . Education had the strongest effect on the relationship between MDE and harmful-dependent drinking . The association between MDE and harmful-dependent drinking was higher among people who lived in urban areas  compared to those living in rural areas .Socio-economic factors modify the association between alcohol use disorder and major depressive disorder among Thai people. Alcohol use disorder (AUD) and depressive disorders are significant public health problems worldwide and both are strongly linked to social conditions , 2. ThesThere is a known relationship between socio-economic status (SES) and mental health –16. AmonThe socio-economic inequalities in mental disorders, including alcohol use disorder and depressive disorders, may be explained by causation and selection processes. Individuals in a lower SES group may experience mental health disorders (causation) because of the high exposure to unfavorable material, psychosocial, and behavioral factors. In contrast, preexisting psychiatric problems impair ones’ ability to attain or retain a higher SES status, leading to a downward SES (selection) .Geographic location, i.e. rural or urban, has been shown to be associated with discrete culture and social environment that may impact people’s behaviors and health condition , 21. In Although there have been several studies investigating the association between depressive disorder and AUD, and between each of these disorders and SES as aforementioned, there is less research on how the association between depressive disorder and AUD may vary across different levels of SES. As all previous literature indicates disparities in the risk of depressive disorder and AUD among people with different levels of SES, it is plausible that the causal link between depressive disorder and AUD might also differ across SES, which may be explained by different capacities between the better-off and disadvantaged depressed individuals in coping with and seeking support for their depressive condition. Based on our literature search, we have found only one study examining the associations between depressive symptoms and alcohol use across socio-economic levels , which wThis study aimed to examine the past 12-month prevalence of major depressive episode (MDE) and alcohol use disorder (AUD) and the association between these two conditions at different socio-economic levels among a population-based sample aged 20 and over in Thailand. Our conceptual framework for this study is that people with MDE would have an increased likelihood for AUD and this association might be modified by socio-economic status variables, including wealth index, education, employment status and area of residence while other factors such as age, sex, marital status and the presence of chronic disease might confound such an association.5 years since 1991. The surveys are designed to represent non-institutionalized Thai populations, using a multistage stratified sampling method, the design of which has been described elsewhere [This study used data from Thailand’s fifth National Health Examination Survey (NHES-5), which was conducted in 2014. Surveys in this series have been conducted approximately every lsewhere . Only daAlcohol use disorder (AUD) was identified based on the 10-item Alcohol Use Disorder Identification Test (AUDIT), a screening instrument developed by the World Health Organization (WHO), which includes questions on the patterns of hazardous and harmful alcohol use and dependence symptoms in the past 12 months . The resQuestions on major depressive episode (MDE) were derived from the Mini-International Neuropsychiatric Interview (MINI), Thai version 5.0.0-Revised 2007 . The intA wealth index based on household assets using the method suggested in the MEASURE DHS+ surveys  was usedOther potential confounding or effect modifying variables included in the analysis were demographic factors such as age, sex and marital status, as well as smoking status and presence of chronic diseases such as diabetes mellitus, hypertension, cholesterolemia, cardiovascular diseases, stroke, and cancer. Diagnoses of diabetes mellitus, cholesterolemia, and hypertension was based on the results of fasting blood sugar and cholesterol levels and blood pressure level, respectively taken at the time of data collection, or a self-report of having been diagnosed by a medical professional as having that medical condition, or being currently on pharmacological treatment for that condition. However, the presence of cardiovascular diseases, stroke, cancers, or other chronic diseases was based on self-report only.All analyses were weighted to take into account the different probabilities of a respondent being selected in the sample. Prevalence was expressed as a percentage. As our objective was to assess the modifying effects of SES and area of residence on the association between MDE and AUD, we first cross-tabulated MDE and AUD across levels of SES and area of residence variables. Then we examined the associations between MDE and either hazardous drinking or harmful-dependent drinking using univariate analysis. We then used multinomial logistic regression to test association between MDE and these variables with AUD. In all models, AUD was the dependent variable with three categories; non-problem drinking (reference category), hazardous drinking, and harmful-dependent drinking while MDE (yes/no) was the main independent variable. Potential confounding variables that we assessed in the analyses included age, sex, marital status, religion, smoking status, and presence of a chronic illness. Next, we assessed effect modifications by wealth index, education, employment, and area of residence by including interaction terms in the models. Wald’s chi-square tests were used to evaluate the significance of these interactions.Lastly, to observe whether the association between MDE and AUD varied by wealth index, education, employment, and area of residence, we then stratified our analyses by levels of the potential effect modifiers whose interaction terms were statistically significant. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were presented to assess the strength of the associations. Statistical significance was evaluated at the 0.05 level and all tests were two-sided.Altogether, 13,177 participants  were included in the analysis. The mean age of the participants was 46.7 years (SD: 15.7) and 70.5% were married or in a de facto relationship. Of all participants, 57.8% had no formal education or had attained only a primary school level of education, 55.6% were employed in labor type work while 34.1% were employed in private or government work, and 10.3% were unemployed; 56.5% were living in rural areas.Based on the AUDIT, 10.3%  and 1.9%  were classified into hazardous drinkers and harmful-dependent drinkers, respectively while 2.5%  met the criteria for MDE in the past 12 months before the survey. Approximately 20%  were current smokers. Chronic diseases were found among 41.7%  of participants, with 10.2%  having diabetes mellitus, 29.2%  hypertension, 11.6%  cholesterolemia, 3.3%  cardiovascular diseases and stroke, 0.8%  cancers and 15.3%  other diseases.The prevalence of MDE varied by all three socio-economic status indicators but not by area of residence. The prevalence of MDE was lower in the groups with higher levels of wealth, education, and among those who were employed Table .Table 1AUD was differentially distributed in different levels of wealth index, education levels, and area of residence. The highest prevalence of harmful-dependent drinking was found among people in the lowest wealth tercile and those with a secondary or higher level of education (12-year schooling). The prevalence of hazardous drinking was significantly higher among those living in rural areas but there was a non-significant difference in the prevalence of harmful drinking between those in urban and rural areas. Furthermore, no significant difference in AUD prevalence was found for employment status , education  and area of residence  were found, indicating that these factors modified the association between MDE and AUD. However, no significant interaction between MDE and employment status  in the association with AUD was seen.Table In this study, data from a large national survey among adults were used to examine the association between MDE and AUD and the effects of socio-economic factors on this association. In agreement with several studies , 29–33 oThe prevalence of MDE was higher among harmful-dependent drinkers and non-drinkers than that in hazardous drinkers, making those with MDE seeming less likely to have hazardous drinking, compared to those with non-drinking behaviors. This should not be simply interpreted as that MDE was a protective factor against hazardous drinking because such an association was not controlled for other confounding factors. In the multivariate analyses when we controlled for confounding factors and stratified by level of SES variables, we found that most of the associations between MDE and hazardous drinking were not significant, and among the significant ones, increased likelihoods of MDE on hazardous drinking were found. Nevertheless, if we explain our findings on the relationship between MDE and AUD in terms of a causal pathway, it could be argued that if depressed individuals use alcohol for self-medication of their depressive symptoms, which are usually chronic, then they may use it in a harmful pattern and be more likely to become harmful or dependent drinkers than hazardous drinkers. This may therefore explain the higher prevalence of MDE among harmful-dependent drinkers than that among hazardous drinkers.In agreement with other studies , the assThe reason that the strengths of association between MDE and harmful-dependent drinking among those in the highest and lowest socio-economic groups were significant and higher than that in the middle group is unclear. On the one hand, it could be explained by the fact that people in the high SES group may have more means to access alcohol or other drugs for self-medication or as a coping strategy when they get depressed. Major depression is a chronic illness and cognitive deficits are frequently observed in those suffering from major depression even at the first episode  which caOn the other hand, people of the lower SES group often face more social difficulties, which enhances susceptibility to negative health outcomes when exposed to risk factors , 15, 41.For both groups of AUD, the significant and strong associations with MDE were found only among those completing secondary school education or higher but not among those with primary school education. The reason for this may be similar to the above explanation for the high socio-economic group and the finding further supports the impact of SES on the relationship between the two disorders. Education is known to causally influence health through mechanisms such as creating a greater sense of control, better working conditions, increased social capital, and improved health behaviors . If it iNo modifying effect of employment status was found on the association between MDE and AUD. The association was only significant for that between MDE and hazardous or harmful-dependent drinking among the employed group. However, the number of unemployed individuals who were depressed and had either hazardous or harmful drinking was low or none, preventing us from determining the effect of employment status on the relationship between MDE and AUD. The inconsistency of the findings by three SES indicators warrants further studies to explicate mechanisms underlying the socio-economic inequality in the relationship between MDE and AUD. As mentioned in other studies, socio-economic inequalities in health may vary depending on the indicators used to measure SES and no single indicator can provide a full picture of SES of the population , 45.Living in a rural area was found to be protective against harmful-dependent drinking in the univariate analysis and a stronger association was found between MDE and harmful-dependent drinking for people living in urban areas compared to those living in rural areas. Evidence of the relationship between urbanicity with depression and alcohol use varies in the literature , 46, 47.Depressive disorders and AUD are common public health problems in Thailand  and prioMental health and many mental disorders are shaped by the social, economic, and physical environments where people live . Our finMoreover, the present research should be helpful for clinical practice. In clinical settings where the prevalence of major depression is usually higher than that in the general population, clinicians should also seek for the co-occurrence of AUD, especially harmful-dependent drinking in depressed patients. On the assumption of a causal process of depressive disorder leading to harmful use or alcohol dependence, it can be indicated that some percentage of patients with AUD may actually improve upon treatment of their depressive disorder. There is a number of studies showing the efficacy of psychological interventions among people with co-occurring alcohol use and depressive disorders . This thThe main strength of this study is the large sample size, nationwide sampling frame, and probability sampling method, making it representative of the general population of the whole country. Furthermore, the possible role of confounding factors such as socio-demographic factors and the presence of chronic medical diseases was taken into account in the analyses. However, there are some limitations that deserve mention. A cross-sectional study is a useful design for obtaining the prevalence of MDE and AUD among the general population, but it cannot establish a causal relationship. The direction of causality is indeterminate; depression and AUD could be reciprocally related to each other by a feedback loop in which drinking increases the risk of depression and the depression leads to an increased consumption of alcohol and related problems . In our This study shows that there is a significant association between MDE and AUD, in particular harmful-dependent drinking. This association is further modified by socio-economic factors such as wealth index, education, and area of residence. Our study further contributes to the growing literature on the social inequalities of mental disorders, which is seen across culture. The varying associations between these two conditions across different socio-economic levels need to be considered when formulating mental health policy for equitable health care and when providing clinical services.


Although smoking and alcohol drinking are established risk factors of esophageal cancer, their public health impact is unclear. Furthermore, the effect of green tea is controversial.The present study was based on a pooled analysis of two prospective cohort studies. A self-administered questionnaire about health habits was distributed to 9,008 men in Cohort 1 and 17,715 men in Cohort 2, aged 40 years or older, with no previous history of cancer. We identified 38 and 40 patient cases with esophageal cancer among the subjects in Cohort 1 (9.0 years of follow-up) and Cohort 2 (7.6 years of follow-up), respectively. Cox proportional hazards regression was used to estimate hazard ratios (HRs) of the risk of esophageal cancer incidence.Cigarette smoking, alcohol drinking and green tea consumption were significantly associated with an increased risk of esophageal cancer. Compared with men who had never smoked, never drunk alcohol or green tea, the pooled multivariate HRs  were 5.09 (1.80-14.40) (p for trend <0.0001), 2.73 (1.55-4.81) (p for trend=0.0002), or 1.67 (0.89-3.16) (P for trend=0.04) for men who were currently smoking ≥20 cigarettes/day, drinking alcohol daily, or drinking ≥5 cups green tea/day, respectively. The population attributable fractions of esophageal cancer incidence that was attributable to smoking, alcohol drinking and green tea consumption were 72.0%, 48.6%, and 22.1%, respectively.Among the variables studied, smoking has the largest public health impact on esophageal cancer incidence in Japanese men, followed by alcohol drinking and green tea drinking. In 2004, 9,405 men died of esophageal cancer in Japan, accounting for about 5% of all cancer deaths.2-18 there might be other factors that increase or decrease the risk. One such factor may be green tea consumption. There have been conflicting data regarding the association between green tea consumption and cancer at various sites, such as the stomach,19,20 lung,21 breast,22,23 and colon.24 Green tea might have another type of influence on the incidence of esophageal cancer, and that is high temperature. Kinjo et al4 have indicated that drinking green tea at high temperature is associated with an increased risk of esophageal cancer mortality. However, their observation was based on a cohort study that started in 1965. Lifestyle-related factors of Japanese people, including green tea consumption, have been changing drastically over the last few decades.Although both smoking cigarettes and drinking alcohol have been consistently reported to be major risks for esophageal cancer,25,26 To our knowledge, no such data are available for Japan.In areas where cigarette smoking, alcohol drinking, and green tea consumption are widespread, the relationship between the use of these three substances and esophageal cancer requires epidemiologic studies. The population attributable fraction (PAF), which is defined as the proportion of disease in the population that is attributable to a given risk factor, is useful for estimating the public health impact of the factor. However, only two studies from the USA and Taiwan have examined PAFs of esophageal cancer using a case-control design.The purpose of the present study was to investigate the risk of esophageal cancer incidence associated with cigarette smoking, alcohol drinking, and green tea consumption in a population-based prospective cohort and to calculate the PAF for each factor if it was significantly associated with such a risk.19,20,22,24,27-29 For cohort 1, we delivered a self-administered questionnaire in January 1984 to all residents aged 40 years or older  in 3 municipalities of Miyagi Prefecture. Usable questionnaires were returned from 31,345  of the subjects. For cohort 2, we delivered a self-administered questionnaire between June and August 1990 to all residents aged 40-64 years  in 14 municipalities of Miyagi Prefecture. Usable questionnaires were returned from 47,605  of the subjects. The study protocol was approved by the institutional review board of Tohoku University School of Medicine. We considered the return of the self-administered questionnaires signed by the subjects to imply their consent to participate in the study.The present study was based on a pooled analysis of two prospective cohort studies conducted in Miyagi Prefecture, Japan. Details of the design for each study have been reported elsewhere.Because women in these cohorts seldom smoked cigarettes or drank alcohol, we limited our analysis to men . We excluded subjects who already had cancer at the time of the baseline survey (258 subjects in cohort 1 and 424 subjects in cohort 2). We then excluded 9,422 subjects  because they did not answer the question on smoking, alcohol drinking, or green tea consumption. Consequently, our analysis included 9,008 men including 38 cases of esophageal cancer in cohort 1, and 17,715 men including 40 cases of esophageal cancer in cohort 2.In both cohorts, the questionnaire included items related to smoking, alcohol drinking, frequency of green tea consumption, and food items consumed.For cigarette smoking, we classified the subjects into four categories: ‘never smoked’, ‘formerly smoked’, ‘currently smoking 1-19 cigarettes/day’, and ‘currently smoking ≥20 cigarettes/day’.For alcohol drinking, we classified the subjects into three categories: ‘never or occasionally drank’, ‘formerly drank’, and ‘daily drinking’. In this analysis, we defined ‘daily drinking’ as those drinking alcohol 5 days or more per week. We also defined ‘occasionally drank’ as those who reported drinking alcohol less than 5 days per week. We did not consider the types or quantity of alcohol beverages they consumed.For green tea consumption, we classified the subjects into four categories: ‘never drank’, ‘drinking 1-2 cups/day’, ‘drinking 3-4 cups/day’, and ‘drinking ≥5 cups/day’.nd Ed.; ICD-O-2).30The end point in this study was the incidence of esophageal cancer defined as topography code C15.0-C15.9 according to the International Classification of Diseases for Oncology .We used Cox proportional-hazards regression to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of esophageal cancer incidence according to categories of smoking cigarettes, drinking alcohol, and drinking green tea, and to adjust for potentially confounding variables, using the PHREG procedure on the SASWe considered the following variables to be potential confounding factors: age in years, cigarette smoking , alcohol drinking , green tea consumption , coffee consumption , and black tea consumption .Interactions among the variables for smoking, alcohol drinking, and green tea consumption were assessed through addition of cross-product terms to the multivariate model. We performed additional analysis to investigate the joint effects of these variables by estimating HRs in combined categories of the variables. For this analysis, the categories of smoking, alcohol drinking, and green tea consumption were divided into currently smoking or other, currently alcohol drinking or other, and currently consuming ≥3 cups/day green tea or other, respectively.Because smoking, alcohol drinking and green tea consumption are modifiable risk factors, we calculated the PAF, an estimate of the proportion of esophageal cancer incidence in Japan that might be avoided if the population were not exposed to these risk factors. PAF was calculated aspd is the proportion of cases exposed to the risk factor.31where 32 All p-values are two-tailed, and differences at p<0.05 were considered to be statistically significant.To obtain a summary measure of the results from cohort 1 and cohort 2, we used the general variance-based method.As compared with subjects who never drank green tea, the incidence risk of esophageal cancer was increased among those drinking 1-2 cups/day , those drinking 3-4 cups/day  and those drinking 5 cups or more/day . In contrast to the higher risk for smoking and alcohol drinking, the risk for green tea was modest. However, we observed a significant dose-response relationship (p for trend=0.04).We further examined the relationship between the risk of esophageal cancer and the consumption of coffee, but found no association. After adjustment for age, cigarette smoking, alcohol drinking, green tea consumption, and black tea consumption, the pooled multivariate HRs (95% CIs) for esophageal cancer in subjects who were drinking 1-2 cups/day, or drinking 3 cups or more/day were 0.63 (0.32-1.27) and 0.94 (0.36-2.45), respectively, compared with subjects who never drank coffee (p for trend=0.41).None of the tests for interactions among the variables of smoking, alcohol drinking, and green tea consumption showed significant results. However, we observed potential effect modifications by analysis of combined categories of these variables. The proportion of esophageal cancer incidence attributable to smoking or alcohol drinking was very high. The PAFs of esophageal cancer incidence attributable to smoking and alcohol drinking were 72.0% and 48.6%, respectively , whereasIn this pooled analysis of two prospective cohorts, we found a significant positive association between smoking, alcohol drinking, green tea consumption and increased risk of esophageal cancer. The HRs were very high when smoking and alcohol drinking were present simultaneously. The PAFs of incident esophageal cancer in this population that were attributable to smoking, alcohol drinking, or green tea consumption were 72.0%, 48.6%, or 22.1%, respectively. To our knowledge, this is the first study to report the PAFs for esophageal cancer from Japan.2-18 Furthermore, the joint effect of these variables is consistent with previous reports.4,5,26,33-35 At least more than additive synergistic effects were shown in four case-control studies5,26,33,35 and two prospective cohort studies.4,34 We also observed very high HRs when smoking and alcohol drinking were present simultaneously.Our results for smoking and alcohol drinking are consistent with those of previous studies.36 only a few studies have evaluated the relationship in humans, and the results were substantially conflicting.4,37 Gao et al37 observed a protective effect of green tea drinking on esophageal cancer incidence among women  but not among men using a case-control study design among Chinese subjects. In contrast, Kinjo et al4 demonstrated that rate ratio and 95% CI were 1.6 (1.2-2.0) for hot tea (drinking green tea at high temperature) in comparison with non-hot tea (drinking green tea at moderate temperature) in a prospective cohort study among Japanese subjects. The results obtained by Gao et al37 may have been affected by recall bias. Using a prospective study design, we observed that green tea consumption was associated with an increased risk, which was consistent with the results of Kinjo et al4 One plausible explanation for our result was the effect of high tea temperature, although we had no information about the temperature of the green tea consumed. However, coffee, which is also generally consumed at high temperature in Japan, was not associated with an increased risk in our study. Therefore, a mechanism other than high temperature may be considered. Our findings for green tea require confirmation by future studies because prospective data on this relationship are scarce.Although studies using laboratory animals have suggested inhibitory effects of green tea on the induction of esophageal cancer,25,26 Engel et al25 from the United States demonstrated that PAFs for ever smoking and any alcohol consumption for esophageal carcinoma in men were 57.6% and 80.2%, respectively. The corresponding figures by Lee et al26 from Taiwan were 63.4% and 66.9%, respectively. In contrast to the previous studies, the PAF for incident esophageal cancer was larger in smokers than in alcohol drinkers in our study. The high PAF in smokers was due to both the higher prevalence of smoking and HR in smokers than in alcohol drinkers. Among the subjects, 57.6% (54.1% for cohort 1 and 59.4% for cohort 2) were current smokers and 48.5% (47.1% for cohort 1 and 49.3% for cohort 2) were daily drinkers. The pooled multivariate HR (95% CI) for esophageal cancer in subjects who had never smoked, formerly smoked, were currently smoking 1-19 cigarettes/day, and currently smoking ≥ 20 cigarettes/day were 1.00, 2.07 (0.66-6.57), 5.00 (1.70-14.66), and 5.09 (1.80-14.40), respectively, while the corresponding values in subjects who never or only occasionally drank, former drinkers, and daily drinkers were 1.00, 1.55 (0.58-4.14), and 2.73 (1.55-4.81), respectively. Our data suggest that cessation and/or primary prevention of smoking have priority over the alcohol issue for reducing esophageal cancer in a population-based manner.With respect to the PAFs of smoking and alcohol drinking, only two reports are available to date.Our study had several strengths. We recruited our subjects from the general population. The information on exposures was obtained before the cases of esophageal cancer had been diagnosed, thus avoiding any effect of recall bias. In addition, the positive association between smoking, alcohol drinking, green tea consumption and the risk of esophageal cancer was unchanged after adjustment for potential confounders.Our study also had some limitations. First, our sample size of 78 cases of esophageal cancer (38 cases for cohort 1 and 40 cases for cohort 2) may not have been sufficient for analyzing the joint effects of the variables, because these analyses were conducted with a higher number of categories than independent analysis. If we had obtained more samples, we might have been able to observe significant results from the interaction tests.Second, because information on exposures was based on self-administered questionnaires and was collected once only, some misclassification of subjects was inevitable. Nevertheless, because the information was collected before subjects developed esophageal cancer or other serious diseases, any misclassification of exposures would likely have been non-differential and resulted in conservative estimates for the association between smoking, alcohol drinking, green tea consumption and the risk of esophageal cancer.Third, we excluded 9,422 subjects  because they did not answer the question on smoking, alcohol drinking, or green tea consumption. Forty-one cases (26 in cohort 1 and 15 in cohort 2) of esophageal cancer were diagnosed in this group. We considered that the characteristics of subjects who did not report these exposures were essentially similar to those of subjects who did, as there was no difference in mean age  and the age-adjusted HR for esophageal cancer in the subjects who did not answer the question about their smoking, drinking, or green tea consumption status, as compared to those who did, was not significant  in cohort 1. Similar results, for both characteristics and HR, were obtained in cohort 2. Corresponding mean ages were 51.3 and 53.6, respectively, and corresponding age-adjusted HR (95% CI) was 1.10 (0.61-1.99). Thus, our results would not be substantially biased by exclusion of the subjects who did not answer the questions on exposures.In conclusion, we have found that smoking, alcohol drinking or green tea consumption is significantly associated with an increased incidence risk of esophageal cancer. To reduce esophageal cancer risk, primary prevention of both smoking and alcohol drinking are essential. Further studies to clarify the role of green tea, consumed at both high and low temperature, in the prevention of esophageal cancer would also be valuable.


Multimorbidity, the coexistence of multiple chronic conditions in an individual, is a growing public health challenge. Amidst the COVID-19 pandemic, physical distancing remains an indispensable measure to limit the spread of the virus. This pertains especially to those belonging to high-risk groups, namely older adults with multimorbidity. In-person visits are discouraged for this cohort; hence, there is a need for an alternative form of consultation such as video consultations to continue the provision of care.The potential of video consultations has been explored in several studies. However, the emergence of COVID-19 presents us with an unprecedented opportunity to explore the use of this technological innovation in a time when physical distancing is imperative. This study will evaluate the sustainability of video consultations on a micro-, meso-, and macro-level by assessing the views of patients, physicians, and organizational and national policymakers, respectively.The NASSS  framework was designed as a guide for the development of health care technologies. In this study, the implementation of and experiences related to video consultations will be studied using the NASSS framework. Individual in-depth interviews or focus group discussions will be conducted with participants using the Zoom platform. Data will be analyzed by at least two investigators trained in qualitative methodology, organized thematically, and coded in two phases—an initial phase and a focused selective phase. All disagreements will be resolved by consulting the larger research team until consensus is reached.This study was approved for funding from the Geriatric Education and Research Institute. Ethics approval was obtained from the National Healthcare Group Domain Specific Review Board (reference #2020/00760). Study recruitment commenced in July 2020. The results of the data analysis are expected to be available by the end of the year.This study aims to evaluate the adoption and sustainability of video consultations for older adults with multimorbidity during the pandemic as well as post COVID-19. The study will yield knowledge that will challenge the current paradigm on how care is being delivered for community-dwelling older adults with multimorbidity. Findings will be shared with administrators in the health care sector in order to enhance the safety and quality of these video consultations to improve patient care for this group of population.DERR1-10.2196/22679 The utilization of remote consultations via telemedicine is not new to the health care scene . StudiesThe COVID-19 pandemic has unexpectedly accentuated the need for remote consultations. In Singapore, the use of telemedicine apps has risen sharply , and dorThe potential of video consultations is of relevance to the geriatric population. Many older adults have multiple chronic conditions or multimorbidity , and reqIn a recent online survey conducted at National Healthcare Group Polyclinics (NHGP) involving 712 patients who had telephone consultations in place of in-person consultations during the COVID-19 pandemic, approximately 95% of respondents agreed to use a telephone consultation again, and 93.1% would recommend it to another person. However, 8% of respondents preferred in-person consultations, citing a lack of personal touch as the main reason. Some of the respondents also complained that they could not see the doctor and would prefer a live video chat instead.Conducting a video consultation may be considered a disruptive innovation since it simultaneously adheres to physical distancing measures during the COVID-19 pandemic while shifting the boundaries of doctor-patient consultations. Studies in other countries have shown that the implementation of telemedicine can be hindered by clinician nonacceptance and conflict with organization culture . The sucAlthough Singapore is a nation with technologically developed infrastructure, levels of comfort with video technologies and tech savviness vary considerably. Communication issues including hearing and language difficulties may be exacerbated when the consultation is not performed in person, especially for older adults. Therefore, it remains to be seen what the benefits and drawbacks of a video consultation might be for older adults with multimorbidity in the Singapore context.While the use of video consultations is promising as an alternative mode of care, extant literature has demonstrated the relevance of sociodemographic factors in patients with multimorbidity. Multimorbidity is known to be more prevalent in socioeconomically disadvantaged groups -20; thisThe goal of this pilot project is to explore the adoption and sustainability of video consultations in order to arrive at a better understanding as to how the current health care system can be improved to ensure levels of care for patients can be maintained through this trying time. We also propose to use the findings acquired from the study as a precursor to further studies that will inform the future implementation of video consultation with family physicians for older adults with multimorbidity in the primary care setting in Singapore.The objectives of this study are as follows:At the micro-level : to study how patients are seen, heard and their needs are met in a safe manner; to explore patients’ and physicians’ acceptance, communication issues and logistical demands, thereby elucidating the features of an optimal video consultationAt the meso-level : to understand and explore the social, technical, financial, and logistical support or lack thereof from the organization, thereby elucidating the requirements for introducing, sustaining, and scaling up of video consultationsAt the macro-level : to understand the current regulatory, legal, professional, sociocultural, political, or policy context, in order to alert key stakeholders to the potential barriers and challenges of video consultation as a regular health care service model in the post–COVID-19 phase.Our research questions are as follows:What features characterize an optimal video consultation and how does the experience differ from an in-person consultation?On an organizational level, what are the factors that affect the implementation of video consultations?What is the national-level context of implementing video consultations as a regular health care service model option in the post–COVID-19 new normal?This is a predominantly qualitative descriptive study for understanding the perspectives of various stakeholders  on video consultation for community-dwelling older adults with multimorbidity in a public primary health care setting in Singapore.Six domains from the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) technology implementation framework  will be All provision of health care services in Singapore is based on the fee-for-service model with various forms of subsidies available for those in need. The government often finetunes the subsidy policies to regulate “the supply and prices of health care services in the country” to keep public sector health care costs in check. However, private medical care is largely subject to market forces.Singaporeans not empaneled to any specific practice and are free to choose the providers within the government or private health care delivery system. The public primary health care services are provided through an island-wide network of 20 outpatient polyclinics, which provide subsidized primary care including primary medical treatment, preventive health care, and health education. In addition, there are up to 1700 clinics run by private general practitioners. For this study, recruitment will be based at NHGP, which consist of six polyclinics located in the northern and central parts of Singapore.Purposive sampling will be used to obtain views from four participant groups for this study: patients, family physicians, organizational implementers/leaders, and organizational/national policymakers. The patient group will include older adults aged 60 years and above with multimorbidity (at least three chronic conditions) being managed by the polyclinic who have undergone at least one video consultation. The family physician group will include family physicians who have conducted at least two video consultations. The organizational implementers/leaders will include members of the senior management team, family physician leaders, or operational staff of NHGP involved in the pilot video consultation project. Lastly, the organizational/national policymakers will include office holders from NHGP and relevant statutory boards or government departments.Potential patient participants will be approached when they visit the clinic for their laboratory tests. Routinely, an in-person consultation will follow one week after their laboratory tests. Patients who are eligible and comfortable to convert their impending in-person visit to video consultation will be referred to a research team member after their laboratory tests. Written informed consent will then be obtained from patients by a research team member in clinic after explaining the study and providing ample time for them to ponder and decide. A convenient time for an individual in-depth interview will be arranged within a week after the scheduled video consultation. All nonpatient participants will be sent an email invitation with information on the study. Written informed consent for nonpatient participants will be obtained by a study team member at their workplace. All study participants will be informed that the interviews  or focus group discussions  will be conducted using an institution-approved secure video conferencing platform and recorded using a digital audio recorder.An estimated maximum number of 60 participants will be recruited: 20 patients (aged ≥60 years with at least three chronic conditions), 15 family physicians, 15 organizational implementers/leaders, and 10 organizational/national policymakers. The recruitment of participants may end earlier if the interview data have reached thematic saturation.Individual in-depth interviews and focus group discussions will be conducted by research team members who have experience in qualitative research. Each interview and discussion is expected to last up to 40 minutes and 90 minutes, respectively. They will be conducted via the institution-approved secure Zoom platform ,23. The Questions at the micro-level will pertain to patients’ and physicians’ experiences of the video consultation . At the meso-level, questions put to organizational implementers/leaders will relate to discovering what factors and processes within the organization contribute to or hinder the successful execution of video consultations. Finally, questions at the macro-level put to organizational/national policymakers will seek to grasp the relevant regulatory, legal, professional, and sociocultural context in which the innovation is implemented, to better understand what challenges may lie ahead if video consultations become a regular service model nationwide. We will be collecting demographic information from patients, including questions on household type, people they live with, and level of IT literacy. We will also engage the family physicians in structured reflective journaling, where they will be asked to provide reflections on their video consultation experiences. This will occur at three different time points , allowing the study team members to understand how their views change over the course of initiating and conducting video consultations.The interviews and focus group discussions will be transcribed verbatim. Another data source will include the reflective journals of the family physicians. Inductive thematic analysis will be carried out by at least two investigators trained in qualitative methodology . They wiCredibility will be achieved through obtaining data from all stakeholders and investigator triangulation . We aim We have obtained ethics approval from the National Healthcare Group Domain Specific Review Board (reference #2020/00760). Study team members will ensure that the necessary precautions are taken to ensure that privacy and confidentiality are maintained, such as using institution-approved secure Zoom accounts that are password-protected and accessible by study team members only.This project received funding from the Geriatric Education and Research Institute under the COVID-19 grant. At the time of writing, no participants have been formally recruited, but clinicians have been contacted and invited to take part in the study. Literature review is ongoing for researchers to stay updated on the state of the field in telemedicine research. Given that this study is qualitative and exploratory, it would be precipitous to anticipate our findings in detail. However, we expect a diversity of opinions both within and between the patient, physician, organizational implementer/leaders, and policymaker groups. The patient and physician groups are likely to show a range of opinions that spans from enthusiasm to reluctance, although the specific reasons for these will need to be elucidated. Organizational implementers/leaders are likely to discuss operational and logistical demands, and their impact on the operation of the whole organization, while we expect policymakers to help us frame the views within a larger overarching context. It is precisely this detail and the divergence in opinions among different stakeholders that will enable us to grasp what challenges lie ahead for the eventual successful implementation and large-scale adoption of video consultation as part of routine care for older adults with multimorbidity.This qualitative study is intended to understand how video consultation can benefit both older adults with multimorbidity and family physicians in Singapore. This is the first study looking into using video consultation in public primary health care in the country.The most recent NHS England long-term plan mandates the availability of video consultations in the next 5 years . CompariThe COVID-19 crisis has led to the introduction of video consultations in Singapore’s public primary health care setting. If found to be appropriate for future use, this study will offer practical guidance on maximizing the adoption of this consultation model for desired clinical outcomes and user acceptance.Before scaling and spreading video consultations in primary care, all stakeholders should be involved in further studies, which will look at proof of concept for clinical outcomes, patient suitability, safety, and minimization of technical issues by referencing qualitative findings from this study; and proof of value for the cost-effectiveness of the model of care. Finally, for the implementation and scaling phases of video consultations, clinical process re-engineering is likely to be necessary to create the clinical, quality educational, business, logistic, and organizational systems necessary to support implementation of video consultations on an enterprise scale.As mentioned above, the digital divide is a reality in Singapore despite its affluence and high levels of general literacy and technological literacy. Subsequent phases looking into full-scale implementation will certainly need to examine the practicability and desirability of making video consultations available to all sociodemographic sectors, providing extra IT support, taking into account a lower level of technological access and literacy among the elderly in economically less-advantaged areas. This future phase will need to examine the specific role video consultations can play in future health care models, whether in supplementing routine consultations or enabling doctors to connect with patients with mobility issues, for example. The present study thus represents only an initial step toward a much larger initiative involving the role of video consultations within the health care system in primary care.