Plasmodium malariae is the most neglected of the six human malaria species and it is still unknown which is the mechanism underlying the long latency of this Plasmodium.P. malariae recurrence in a 52-year old Italian man was observed 5 months after a primary attack. In the interval between the two observed episodes of malaria the patient denied any further stay in endemic areas except for a visit to Libya, a country considered malaria-free. Genomic DNA of the P. malariae strain using five microsatellites  and the antigen marker of circumsporozoite (csp) was amplified and sequenced. Analysis of polymorphisms of the P. malariae csp central repeat region showed differences between the strains responsible of the first and second episode of malaria. A difference in the allele size was also observed for the sequence analysis of PM2 microsatellites.A case of PCR-confirmed Plasmodium malariae is a challenging human malaria parasite and even with the use of molecular techniques the pathogenesis of recurrent episodes cannot be precisely explained.The online version of this article (10.1186/s12936-019-2806-y) contains supplementary material, which is available to authorized users. Plasmodium malariae is the parasite responsible of quartan malaria with the typical periodicity of fever paroxysm observed every 72-h as detailed in a study by Camillo Golgi in 1886, but also described in the fourteenth Century by Dante Alighieri in the Divine Comedy (seventeen Canto of the Inferno) [Plasmodium falciparum, especially in sub-Saharan Africa, where it might easily be overlooked if molecular techniques such as polymerase chain reaction (PCR) are not used for diagnosis [P. malariae can occur even after 30–50 years following a previous malaria attack, the mechanism responsible for its persistence and late recurrence still remains a medical mystery [P. malariae is not a relapsing Plasmodium species, thus still giving the Bignami’s interpretation of endo-erythrocytic persistence of the parasite as the more satisfactory [P. malariae hypnozoites has never been proven is not “per se” a proof against it. For instance Plasmodium ovale is credited to produce hypnozoite although P. ovale hypnozoites have never been demonstrated biologically. Herein it is described a case of P. malariae infection in an Italian man occurring 5 months after a previous malaria episode despite the fact he had not travelled to a malaria-endemic region. A review of similar cases is also described together with possible explanation of this phenomenon.Inferno) . The pariagnosis . Althougsfactory . HoweverP. malariae. He was treated with a standard regimen of oral chloroquine phosphate . Subsequently he was in good health until the end of April when fever recurred spiking to 40 °C associated with severe headache. On 4 May, 2018 he presented to the ED of another hospital where a blood smear was positive for trophozoites of Plasmodium spp. He was transferred to the ED of L. Sacco hospital where a new blood smear showed scanty trophozoites of P. malariae; RDT was negative and species-specific PCR confirmed the diagnosis of P. malariae. Clinical examination was remarkable for the presence of herpes labialis, but otherwise negative. A chest X-ray was negative and blood examinations showed increase C-reactive protein (201 mg/L) mild anaemia , leukopaenia (WBC 3200/μL) and thrombocytopaenia . In the period between the two P. malariae episodes he admitted only a short stay in northern Africa (Libya) without any other trip to sub-Saharan Africa. He was admitted to the Infectious Diseases Ward and treated with a 3-day course of dihydroartemisinin–piperaquine (320/40 mg) 4 tablet/day for 3 days. He was discharged on 8 May, 2018 with negative blood smear and PCR for malaria. On follow-up he had normalization of blood examinations and up to January 2019 no more recurrences of malaria.A 52-year-old Italian man sought care at the Emergency Department (ED) of Luigi Sacco Hospital in Milan, Italy on 14 December, 2017, complaining of a quartan pattern of fever that started 1 week before together with arthralgia and myalgia. He reported frequent trips to sub-Saharan Africa, the last one to Mozambique and several previous malaria attacks treated by himself using quinine. He reported to have not taken anti-malarial chemoprophylaxis. A chest X-ray was negative and laboratory examinations were unremarkable except for an increase of C reactive protein (50.9 mg/L) and mild thrombocytopaenia . A blood smear was negative for malaria parasites as well as a rapid diagnostic test (RDT), but species-specific PCR turned positive for Plasmodium malariae genomic DNA was extracted from 200 μL of whole infected blood samples collected from the patient at both hospital admittances, using PureLink Genomic DNA Kit-Invitrogen. Five microsatellites (MSs)  and the antigenic marker P. malariae circumsporozoite (Pmcsp) gene were genotyped, by PCR amplification and sequencing, in P. malariae isolate(s) responsible for the patient’s infection in order to compare the primary infection and the second episode.Pmcsp gene, two internal primers were designed specifically and used to amplify the central repeat region of the gene  and on second admission  was performed by direct sequencing of the amplified fragments of six P. malariae molecular markers.Comparison of the genetic diversity of P. malariae AND “recrudescence” AND “recurrence” AND “relapse”. Several cases were added by cross-referencing the articles cited in the retrieved case reports. Articles in Chinese, Russian and Japanese languages were excluded.A PubMed, Scopus and EMBASE literature search was performed from 1940 to 2018 with the search terms Pmcsp gene and three MSs  were successfully sequenced in patient’s two blood specimens. The result of the sequencing of PM11 and PM25 showed the amplification of non-specific bands, resulting in a cross-reaction with human DNA, and for this reason these two molecular markers were excluded by the present analysis.In each of two tested DNA samples, a single amplified product was observed on agarose gel for each analysed target, suggesting the presence of a single detectable isolate for each malaria episode. The central region of Pmcsp central repeat region resulted in the amplification of a DNA fragment of 864 base pairs (bps) (288 aminoacids) in the isolate responsible of the first episode, with a repeat region characterized by two NDAG tetrapeptide repeat units followed by 51 NAAG tetrapeptide repeat units. The isolate collected from the second episode had a more complex structure of the central repeat region (NDAG3 + NAAG1 + NAAG5 + NDAG1 + NAAG9 + NDAG1 + NAAG20) for a total length of 816 bps (272 aminoacids)  due to a repeat unit region of 68 nts; instead, the second isolate collected in the second hospital admission showed an allele size of 216 nts with a repeat region of 92 nts  and PM34 microsatellites (295 nts).The sequence analysis of PM2 displayed two different size variants: P. malariae recrudescence were retrieved from the literature and are summarized in Table P. malariae recrudescence was published by Shute in 1944 in The Lancet and the same author in a review regarding imported malaria in the UK cited another two observed cases occurring after 10 and 15 years [Twenty-three case reports of 15 years , 32.TablP. malariae infection was based on microscopy only and the long latency before the recrudescence was inferred by the notion about elimination of malaria in the country of origin or by the last time in which the patients lived in or travelled to an endemic area [P. malariae in 4 patients consistent with the possibility of initially overlooked mixed infections [P. malariae recrudescence diagnosis, a nephritic syndrome was observed in two patients [In the oldest cases recorded the diagnosis of mic area , 19–21. mic area –19, 26. mic area , 19, 21.fections , 23, 25.fections . Splenomfections –21, 31. patients . ChloroqPlasmodium malariae is the most neglected among Plasmodium species responsible of human malaria, being frequently undetected due to the very low parasitaemia it causes. Only recently a draft nuclear genome and a high-quality reference genome of P. malariae have been made available but nevertheless this Plasmodium remains the most mysterious among human malaria parasites and its long-term persistence has so far been elusive to any convincing explanation [Plasmodium rhodaini and Plasmodium brasilianum) has raised the question whether P. malariae should be considered a zoonosis, an anthroponosis or as inferred by Lalremruata et al., at least in South America, P. malariae and P. brasilianum are a single anthropozoonotic species [lanation , 34. Mor species –37.P. malariae infection even after more than 50 years of latency have been described in old malaria literature  have been previously reported [P. malariae in which the minority initial subpopulation survived after treatment with AL and they postulated the need to use artemisinin combination therapy (ACT) with long half-life partner drug and longer follow-up of patients with P. malariae. Another possibility to be investigated as proposed for P. falciparum is the sequential use of two artemisinin-based combination regimens [P. malariae chloroquine-resistant episode has been described, the decision was to treat the second episode of malaria with dihydroartemisinin–piperaquine (DHP) with no malaria recurrence after 8 months of follow-up [P. malariae infections it is presently unknown for how long a patient should be followed and, in clinical practice, among travellers with imported malaria follow-up longer than 4 weeks seems unfeasible [P. malariae among travellers using atovaquone–proguanil chemoprophylaxis, Teo and co-workers showed the absence of mutation in the parasite locus pmcytb associated with recrudescence of P. falciparum [P. malariae is a relapsing parasite with the capacity to undergo latent hypnozoites in the liver responsible of new erythrocytic sexual replication years after the initial infection. Based on the life span of erythrocytes (110 days) and of hepatocytes (150–300 days), Richter et al. [P. malariae. However, Garnham, based on several observations concluded that “P. malariae are recrudescences of persisting blood forms of the respective parasites” [However, recurrence of reported , 23, 28.reported  describeregimens . As far ollow-up . Howeverfeasible –21, 23. lciparum . These ir et al.  concurrerasites” .P. malariae infection, raised also the possibility that this patient harboured several different population of P. malariae acquired at different time frames with different fitness to anti-malarial drugs, one of which was capable of emerging when the susceptible ones were eliminated [Moreover, it is hard to explain how a dormant liver parasite is responsible of malaria transmitted by blood transfusion by an asymptomatic blood donor as long as 44 years after the last exposure in a malaria endemic area –47. The iminated .P. malariae with a state of balanced parasitism which can be abruptly broken by stress events, such as surgery or removing the spleen or by treatment with immunosuppressive drugs, each one responsible for recrudescence of malaria [P. malariae to escape drugs which are blood schizontocidal for P. falciparum despite the very low parasitaemia that the former parasite produces. It can be speculated that in view of the long pre-patent period of P. malariae the duration of therapy against this Plasmodium should be increased and when using an artemisinin combination, as suggested by Rutledge et al., a partner drug that is slowly eliminated should be preferred [The review of the literature confirms the importance of immunity in controlling long-term latency of  malaria , 19, 21. malaria , 22–31. referred , 33.P. malariae recrudescence, together with explaining hypothesis and a review of the literature of long-latency recrudescences. One-hundred and sixty-five years after its description P. malariae remains the most mysterious of the human malaria parasites and as suggested by Shute “it provides an almost perfect example of successful parasitism, without the frequent change of host need by other species of human malaria” [P. malariae persistent parasitism take again the hypnozoite hypothesis based on the fact that the “not proven existence”  should not be considered as proof for the non-existence of P. malariae hypnozoites and the need to search for an alternative place of dormancy, such as the spleen [It is described a case of probable malaria” . Severale spleen , 48–50.Additional file 1: Figure S1. Phylogenetic tree inferred from CSP nucleotide sequence alignment obtained from P. malariae isolates analyzed in the present study  and from 12 representative CSP gene sequences retrieved from the GenBank database. P. vivax CSP gene sequence (Genbank accession number AJ295636) was also included in the analysis and used as an outgroup. Phylogenetic analysis was done using the neighbour-joining method constructed using the neighbor-joining method by bootstrapping with 1000 replicates, and phylogenetic distances were measured by Tajima-Nei model, using the Accelrys DS Gene software package .Additional file 2: Figure S2. Phylogenetic tree inferred from PM2 microsatellite sequence alignment obtained from P. malariae isolates analyzed in the present study  and from all representative sequences of PM2 microsatellite retrieved from the GenBank database. Phylogenetic analysis was done using the neighbour-joining method constructed using the neighbor-joining method by bootstrapping with 1000 replicates, and phylogenetic distances were measured by Tajima-Nei model, using the Accelrys DS Gene software package . Reference: Tajima F, Nei M. Estimation of evolutionary distance between nucleotide sequences. Mol Biol Evol. 1984;1:269–85.


The relationship between alcohol use in adolescents and young adults and outcomes has not been widely researched in China. The aim of the current study was to understand the current status of drinking behavior of Chinese youth transitioning into adulthood.The cross-sectional study included 1634 participants between 18 and 34 years of age. The participants were randomly chosen from 13 administrative districts in Wuhan, and invited to complete a questionnaire. Univariate analysis was performed to describe the demographic distribution of alcohol consumption and the association with drinking status. Stepwise Logistic regression analysis was undertaken analyzing the factors influencing the drinking behaviors. The data were weighted to the population in Wuhan and analyzed using SAS version 9.3.For our sample of emerging and young Chinese adults the prevalence of drinking alcohol was 45.84%. The non-drinkers predominated, accounting for 54.16% and light drinkers accounted for 42.94%, while moderate and heavy drinkers were in the minority (2.90%). The earlier the age of first alcohol drinking or the age of first being intoxicated, the greater the likelihood of being a moderate or heavy drinker. People with high emerging adulthood were more likely to have moderate or heavy drinking behaviors. The logistic regression analysis indicated that heavy drinkers were more likely to not be married and to be classified as high emerging adulthood.Our findings suggested that the drinking pattern should be further evaluated over time to explore the ways in which social and cultural factors shape the drinking route of this age group. Effective drinking behavior prevention and interventions and appropriate guidance should be formulated to establish an appropriate attitude towards drinking alcohol and develop a drinking behavior which is conducive to physical and mental health between this particular demographic. According to the World Health Organisation’s 2014 estimate, 5.1% of the global disease and injury burden can be attributed to drinking alcohol , which pIn China, drinking alcohol is a widely accepted cultural tradition, especially during rituals, festivals, social gatherings, commercial occasions and special activities . Based oCompared with other countries, early research on alcohol in China focused on the etiology of adults, mainly containing the physiological and clinical analysis. In recent years, investigations have begun to pay closer attention to alcohol-related health harm  , 20–22 aWithin the literature no one age is identified as the exact point of transition into adulthood. Within the literature there is broad agreement that the point of transition occurs somewhere between late adolescence and the age of more than 30 –34. GiveThe data were derived from a trans-national population-based survey covering four cities  in four countries. In the current paper, the Wuhan data was used to investigate the drinking behavior among emerging adults and young adults (18–34 years old) under a specific social and cultural background in China. The method part refers to the published papers by Anne and Bridgette .This study received ethical review and approval from the Hubei Provincial CDC . Before further investigation, the interviewers conducted household confirmation, informed consent, and investigation management issues. The interviewers must introduce the content and purpose of the survey according to specific introductions and obtain verbal informed consent from all participants. Participants could terminate the interview at any time, or choose not to answer any question. Confidentiality of information was assured. Approval for the research was obtained by community leaders, appropriate government officials and other important related personnel. Households with alcohol and substance abuse could be referred to recognized hospitals/caregivers for proper management.2. Wuhan was pragmatically selected as a research site based on its diversity. Wuhan is divided into 13 administrative regions, and the multi-stage random sampling was performed across each region. The sample size of each administrative district was proportional to the population size. Communities were randomly selected in each administrative district, followed by random household selection. In each randomly selected household, the person with the most recent birthday, aged between 18 and 34 years, who lived in Wuhan for at least six months, was eligible and was invited to participate in the study. Prior to the main survey, 33 pilot interviews were conducted. The pilot assessed participants’ understanding of the questions and length of the interview.Wuhan is the capital of Hubei Province, and at the time of the survey it had a population of approximately 9.8 million and a geographical area of about 8467 kmData collection lasted for 186 days (2014.10.25–2015.04.29). Door-knocking interviews were conducted in Chinese and the Wuhan local dialect by the interviewers who were local college students with specialized training. The data was obtained through face-to-face interviews, which is better for mutual understanding between interviewee and interviewer. Interviewers read out the questions and recorded via paper-and-pencil. Interviews were conducted in an environment where respondents felt most comfortable and where their privacy was respected. The average interview time was 15 min. In total 1675 individuals were approached and 1675 participants agreed to be interviewed. After screening 1646 were identified as eligible to be interviewed. Of these 1642 interviews were completed. Two interviews were excluded due to insufficient completion of demographic information; demographic information is necessary for weighting. A further six cases were excluded due to incomplete drinking information. A total of 1634 questionnaires were included in the current analysis. The response rate was therefore 99.3%.Main alcohol questions included: (1) Have you ever consumed alcohol (excluding sips). (2) How old were you the first time you had a drink of an alcoholic beverage (excluding sips)? (3) How old were you the first time you got drunk? (4) During the past 12 months, how often did you drink beer, wine, spirits , huangjiu or any other alcoholic beverage, even in small amounts? (5) During the past 12 months, how many alcoholic drinks did you have on a typical day when you drank alcohol? (6) In the past 12 months, how often have you ever gotten drunk? ? (7) Drinking alcohol may impose various effects on people. When you are drinking, on what extent of the following statement may fit your situation ? The effects including positive and negative effects, such as feel happy, feel relaxed, become aggressive toward other people, and so on.Overall quantity-frequency  was calculated by multiplying the responses to the above two questions (how much and how many) with 25 or more drinks (coded as 25), 19–24 drinks (coded as 21.5), 16–18 drinks (coded as 17), 12–15 drinks (coded as 13.5), 9–11 drinks (coded as 10), 7–8 drinks (coded as 7.5), 5–6 drinks (coded as 5.5), 3–4 drinks (coded as 3.5), 2 drinks (coded as 2), 1 drink (coded as 1) and less than 1 full drink (coded as 0.5). The annual number of drinks was calculated by multiplying the responses to the question on how many days did you drink alcohol with the response from how many drinks did you have. The variables were recorded into four drinking status groups: 0 drinks = Abstainers; > 0 but less than 365 drinks/year = Light drinkers; 365–729 drinks/year = Moderate drinkers; 730 or more drinks/year = Heavy drinkers. No distinction was made between lifetime abstainers and former drinkers with alcohol consumption assessed during the past 12 months only. These four groups were collapsed into two groups of non-drinkers and current drinkers. ‘Non-drinkers’ referred to those who have never drunk before (‘Lifetime abstainers’) and those who have not drunk in the past 12 months (‘Former drinkers’). ‘Current drinkers’ referred to those who have either drunk more than half a cup of alcohol at least once in the past 12 months or those who have drunk any quantity of alcohol at least twice in the past 12 months.Pure alcohol intake (grams per day) was calculated by multiplying the responses to questions about how often and how much—and then the units were converted . Respondents were provided with visual references to beverage specific drink sizes in order to facilitate reporting of number of drinks in standard sizes.The interview also included an assessment of emerging adulthood which included the following three statements: a) I have reached adulthood. b) I am financially independent of my parents. c) I am emotionally independent of my parents. Questions were answered on a five-point Likert scale: 5 = strongly agree; 4 = agree; 3 = neither agree nor disagree; 2 = disagree; 1 = strongly disagree. Responses were totaled with 3–11 points indicating low emerging adulthood, 12–13 points indicating medium emerging adulthood, and 14–15 points indicating high emerging adulthood. The emerging adulthood statements were based on the work of Arnett and Padilla-Walker  and adapIn this study, the data were ranked weighted as per the stratified target population information provided by Hubei Provincial Institute for Health Education in 2014 by Administrative District, age, gender and selection probability. The weight value distribution range was 0.285–4.300. The aim was to minimize bias and ensure that samples were representative; the weighted demographics of the sample were consistent with the local demographics.χ2 test. The rank test was used for group comparison of grade data. Simple univariate analysis was performed to describe the demographic distribution of alcohol consumption and the association analysis of drinking status. Stepwise Logistic regression analysis was undertaken analyzing the factors influencing the drinking status among the population between 18 and 34 years of age in Wuhan, controlling for the socio-demographic characteristics and adult tendency. In addition, the relationship between emerging adulthood and drinking behavior was assessed. The significance was set at p < 0.05.The data base was built with EpiData version 3.1, and the logical verification and statistical analysis of the data were carried out using the 9.3 version of the SAS statistical analysis package. Demographic characteristics included age, sex, marital status, education level, current student status and employment status. Group comparison of categorical data was using CMH-χ2 = 10.14, p = 0.0015); Students had a higher proportion of drinking than non-students ; People with high emerging adulthood had a higher proportion of drinking . Figure A total of 1634 people were included in the current analysis. Of these 749 (45.8%) were current drinkers. Chi-square statistics were calculated to assess the drinking distribution difference between different demographic characteristics and emerging adulthood ; People who were not married had a higher proportion of heavy drinkers ; People with high emerging adulthood had a higher proportion of heavy drinkers .Participants were divided into four categories: non-drinkers, light drinkers, moderate drinkers and heavy drinkers. The non-drinkers predominated, accounting for 54.2% of the population, followed by light drinkers (42.9%), moderate drinkers (1.7%) and heavy drinkers (1.2%). The drinking status between different demographic characteristics and emerging adulthood are shown in Table p = 0.0129) or a first drunk age  before 15 years of age, had a higher proportion of moderate or heavy drinkers than that after the age of 15; No significant relationship was observed for females . Overall, the earlier the first drinking age, the higher the level of current drinking . When exploring the relationship between drunkenness and negative effects among current drinkers, the incidence of intoxication was 33.6% for those who linked drinking with negative effects, while for people who did not consider drinking with negative effects, the incidence of intoxication was 18.7%, a difference of 15.0% (95% CI (0.081–0.205), p < 0.0001).The results of the rank test Table  indicatep < 0.0001) and higher emerging adulthood (p = 0.0030), with heavy drinkers more likely to be people not married, and with higher emerging adulthood.Stepwise regression methodology was used to determine the model for demographic characteristics and drinking status; age, marital status and emerging adulthood were positively related to drinking status Table . There wp = 0.0897). The correlation coefficient of emerging adulthood and the highest alcohol intake (grams per time) was 0.76 (p = 0.0111). Similarly, in the Fig. p = 0.0165). The correlation coefficient of emerging adulthood and the highest drinking frequency was 0.52 (p = 0.1276). The correlation coefficient of emerging adulthood and frequency of being drunk was 0.52 (p = 0.1221). Figure Figure This is the first study aimed at evaluating the drinking behaviors and its related factors among emerging and young adults in China. The current study suggests that the majority of people aged 18–34 years living in Wuhan who consume alcohol could be considered ‘light drinkers’. Although the incidence of heavy drinking is not high among this population when extrapolated to the number of individuals across China, this represents a substantial challenge for public health. In addition, we cannot predict whether light or moderate drinkers will engage in dangerous drinking behaviors in the future. Public health prevention and intervention efforts in China should strengthen and develop an appropriate attitude towards drinking alcohol. There is also a need to develop effective interventions for the relatively few, but substantial in number, heavier drinkers in order to minimize the costs associated with problematic drinking behavior.The influence of gender on drinking behavior has been demonstrated in many studies. Some alcohol studies reported that males were more likely to consume alcohol than females, and females were more likely to be abstainers –39. In oPrevious studies have noted a first drinking age of 15 years or earlier was at elevated risk for alcohol abuse and dependence , 47. TheThe current results concerning emerging adulthood found an association between emerging adulthood and drinking behaviors. Heavy drinkers were more likely to be people with higher emerging adulthood. Furthermore, people with higher emerging adulthood usually had more extreme drinking alcohol behavior with higher frequency. Previous studies suggested that young adults reduce risk drinking behavior to more moderate levels of alcohol use when adult roles and responsibilities are taken on –56. Our Our research also indicated a link between the alcohol consumption of the four types of alcoholic beverages  and emerging adulthood scores, which have shown that among the four most common types of alcoholic beverages in China, the annual alcohol consumption of beer was significantly highest, which supported the fact that China is one of the largest beer consuming countries in the world .Study limitations include the fact that the study was cross-sectional, which restricts our assessments of the temporal relationships of the associations. The data was limited to one city and the results were not nationally representative. Concerns around the length of the structured interview and lack of availability of a validated brief assessment of ‘emerging adulthood’ meant the current study created a measure based on the work of Arnett and Padilla-Walker . The stuThe research focused on the alcohol drinking behaviors of this particular age group, and the findings of the present study strongly supported the significant impact of social and cultural background and age-specific characteristics on the drinking behaviors. For China,, China-specific influences together with assessment of adulthood level are important considerations when developing effective drinking interventions for emerging and young adults. Internationally, this country-specific study increases the understanding of Chinese drinking characteristics and provides valuable reference for international alcohol-related surveys.


HNF1A) maturity‐onset diabetes of the young (MODY) is a monogenetic, autosomal dominantly inherited form of diabetes. HNF1A‐MODY is associated with HNF1A‐inactivated hepatocellular adenoma (H‐HCA) formation. Hepatocellular adenoma (HCA) are benign liver tumours and related complications are rare but serious: hepatic haemorrhage and malignant transformation. Guidelines recommend resection of all HCA in men and do not take any co‐occurring metabolic disorders into account. We report a family with HCA preceding diabetes mellitus. Male index patient presented with numerous, irresectable HCA. After initial diagnostic and aetiologic uncertainty HNF1A germline mutation c.815G>A (p.Arg272His) was confirmed 8 years later. No HCA‐related complications occurred. His diabetic mother was diagnosed with HCA after severe hepatic haemorrhage years before. HNF1A‐MODY should be considered in (non‐)diabetic  patients with H‐HCA. We advocate liver biopsy and, if necessary, genetic analysis to precede any intervention for HCA in males and screening for HCA in HNF1A‐MODY patients.Hepatocyte nuclear factor 1A ( DMdiabetes mellitusHCAhepatocellular adenomaH‐HCAHNF1A‐inactivated HCAHNF1Ahepatocyte nuclear factor 1ALAliver adenomatosisMODYmaturity‐onset diabetes of the youngMRImagnetic resonance imaging1HNF1A) gene, HNF1A‐MODY (formerly MODY3) is the most common subtype. HNF1A‐MODY is associated with diabetes onset before the age of 25 years and gestational diabetes, and is treated best with sulfonylurea derivatives.Maturity‐onset diabetes of the young (MODY) is a monogenic, autosomal dominant, non‐ketotic form of diabetes mellitus (DM), representing genetic, metabolic and clinical heterogeneity. Because of a heterozygous germline mutation of the hepatocyte nuclear factor 1A  formation.HNF1A germline mutation in one allele, thereby causing H‐HCA formation following a second, somatic mutation in the wild‐type HNF1A allele.HNF1A mutations, although MODY is typically diagnosed prior to H‐HCA.Transcription factor 2HNF1A germline mutation and high penetrance of H‐HCA. Information was obtained from the electronic patient file after all patients gave consent. Immunohistochemistry was performed to analyse tissue samples for expression of c‐reactive protein (CRP), serum amyloid A (SAA), liver fatty acid binding protein (LFABP) and glutamine synthetase (GS). Genetic analysis after leucocyte DNA extraction was performed by next‐generation sequencing of the MODY gene panel. The panel involves 13 MODY genes: HNF4A, GCK, HNF1A, HNF1B, PDX1, NEUROD1, KLF11, CEL, PAX4, INS, BLK, ABCC8, KCNJ11 and included multiplex ligation‐dependent probe amplification. Follow‐up for all family members by magnetic resonance imaging (MRI) was at least 2 years.We report a family with a 3A 25‐year‐old man Figure B. HistolDuring laparotomy, an extensive, liver‐wide spread of tumours, ranging in size from microscopic up to 40 mm was observed—preventing any tumour‐free hepatic remnant Figure C. Histolc.815G>A (p.Arg272His), in the HNF1A gene DNA‐binding homeodomain, confirming HNF1A‐MODY. Hepatobiliary contrast‐enhanced MRI visualized three small liver tumours, highly suspected for HCA. This germline mutation and HCA diagnosis led to aetiologic reconsideration of the HCA and DM in the index patient. Subsequent genetic analysis of the index patient confirmed the same germline mutation in the HNF1A gene. She had used an estrogen‐containing oral contraceptive pill for 18 years at the time of diagnosis.One year before, index patient's sister Figure A, III:3 HNF1A gene  in exon 4, c.815G>A (p.Arg272His) has previously been described.The expression of the diabetic phenotype of HNF1A‐MODY is regulated by modifier genes.HNF1A gene are found. We advocate pre‐operative percutaneous liver biopsy and immunohistochemical and genetic analysis of both liver tissue and peripheral blood for HNF1A mutations if multiple steatotic HCA are diagnosed in male and female (diabetic) patients. Subsequent wait‐and‐see policy should be guided by alpha‐foetoprotein and adequate imaging.HNF1A‐MODY should always be taken into consideration when H‐HCA are diagnosed, even without concurring DM and especially if mutations in the DNA‐binding domain of the Diagnosing HNF1A‐MODY accordingly may prevent H‐HCA‐related complications, and allow for correct diabetes treatment for both the patient and his or her family. Even without clinical signs of DM, ruling out HNF1A‐MODY may be relevant especially in men with H‐HCA. For men diagnosed with concurring HNF1A‐MODY, close monitoring might be more appropriate. Although the (bleeding) risks of their HCA should not be underestimated, the current dogma to always intervene with surgical intervention should be reconsidered.None of the authors declared conflict of interest.All authors contributed to the drafting and revision of the manuscript. They interpreted the clinical information from their specialty and supervised the correct interpretation of results.


Life within a gang includes two endemic features: violence and alcohol. Yet, to date, most researchers studying gang behavior have focused on violence and its relationship to illicit drugs, largely neglecting the importance of alcohol in gang life. Because alcohol is an integral and regular part of socializing within gang life, drinking works as a social lubricant, or social glue, to maintain not only the cohesion and social solidarity of the gang, but also to affirm masculinity and male togetherness. In addition to its role as a cohesive mechanism, particular drinking styles within gangs may operate, as with other social groups, as a mechanism to maintain group boundaries, thereby demarcating one gang from another. Other examples of internal gang violent activities associated with drinking include fighting between members because of rivalries, tensions, or notions of honor or respect. At a more symbolic level, drinking is associated with two important ritual events in gang life: initiation, or “jumping in,” and funerals. By better understanding the link between drinking and violence among youth gangs, steps can be taken to determine the social processes that occur in the development of violent behavior after drinking. Social commentators have had a longstanding interest in and preoccupation with youth groups and violence. Even in Victorian England in the late 19th century, commentators were preoccupied with the apparent escalation in disorder among young violent working-class youth gangs in the industrial cities of Birmingham, Liverpool, and Manchester , p. 72. In spite of the importance of drugs within the social life of gangs, the recent preoccupation of research on illicit drugs has overshadowed the importance of drinking within youth gangs and its possible relationship to violent behavior. To date, little research has been done specifically on the role of alcohol within the social life of gangs, and consequently, it is a relatively unexplored area. The available research data on the role of alcohol in youth gangs has been, to paraphrase Dwight aOver the past decade, researchers and public health officials have become increasingly concerned with the increased involvement of youth in violent crime. The juvenile male arrest rate for violent crime offenses increased steadily during the first half of the 1990s, peaking in 1994 with a rate of 880, and then beginning to drop, with an arrest rate of 545 in 1999. Among females, the juvenile arrest rate for violent crime also has risen, peaking in 1995 at 158 and then leveling off at 122 in 1999 aa. WithinViolence is endemic to gang life. As In the same way that violent behavior is a common currency within gang life, so also is drinking. Although few researchers have looked specifically at the role of alcohol within the social life of gangs, some gang researchers have noted that drinking is a major component of the social life of gangs and a commonplace activity . TherefoTo understand the role of alcohol in the lives of gang members, we must begin our analysis by considering the characteristics and dynamics of street life. As many researchers have noted, being on the streets is a natural and legitimized social arena for many working-class, minority male adolescents. For many of these young men, life is “neither the workplace nor the school; it is the street” , p. 102.Gang members spend the majority of their day “hanging around” , or “jusPartying is a focal event in the life of gang members in which binge drinking is an integral component .Partying overlaps with gang members “hanging out,” and gang members “party” both at public dance places, bars, and parks in the neighborhood or at private parties held in hotel rooms or at someone’s home or garage. Sometimes private parties are arranged formally, organized either for celebrations or, on some occasions, for grieving. Like hanging out, partying also operates to maintain and enhance the cohesion of the group .Drinking works in several symbolic ways in the gang. Because drinking is an integral and regular part of socializing within gang life, as the Studies of African-American gang life suggest the construction of a different cultural identity, one in which “the overall street style and the desired approach to projecting an individual’s personal image can be summed up in the word ‘cool’” . In thisIn addition to its role as a cohesive mechanism, particular drinking styles within gangs may operate, as with other social groups , as a meOther examples of internal gang violent activities associated with drinking include fighting between members because of rivalries, tensions, or notions of honor or respect. Tensions may arise when two gang members or cliques compete for power or status within the gang or when two members compete over the affection of another. After bouts of drinking, these simmering rivalries may erupt, and fighting often occurs. In such cases, as other researchers have noted, alcohol works to create a ritualized context for fighting and violent confrontations, whether physical or verbal , in whicAt a more manifestly symbolic level, drinking is associated with two important ritual events in gang life. For many gangs, new members are expected to go through an initiation, often referred to as “jumping in.” This induction process, or rite of passage, is important, because it is designed to symbolically test the newcomer’s toughness and his ability to defend himself and withstand physical violence. The ritualized physical testing of potential group members is a common occurrence in many societies and has been described and analyzed by many anthropologists. As Funerals are the second ritual events in gang life in which alcohol and violence are associated. Here, gang members in mourning use alcohol to represent their connectedness to the dead homeboy. They pour alcohol over the grave or leave alcohol at the graveside to symbolize their unity. For example, Campbell describes an incident in which each gang member, during a drinking session, ritually poured alcohol onto the floor prior to drinking from a bottle of rum, which was being passed around: “. . . he pours a little of the rum on the ground in memory of those who are dead or who are in jail” , p. 55. In addition to those violent activities internal to the gang, violence between opposing gangs is another frequent and common activity that is associated with drinking. Different types of activities include the following: violence targeting a member or members of a rival gang, violence against residents of the gang’s own neighborhood, and violence against gangs or residents of another neighborhood . The reaAlthough gang members expressed no overall agreement on the issue of whether alcohol improved their ability to fight, two features were clear. First, confrontations between rival gang members frequently took place while gang members were drinking. Second, in spite of disagreements as to the precise effects of alcohol, many of our respondents admitted that drinking assisted them to develop a sense of “locura” , or “pumThus, alcohol may be perceived as the catalyst for violent incidents, either because drinking was more likely to lead to fighting or because, once drunk, the gang members did not care what happened. Violent confrontation with another group may be senseless and provoked by a drunken fellow homeboy; nevertheless, because of their notions of respect and honor, the members must still defend their homeboy. These violent activities, which are encouraged by the young men drinking, work to bind the group together . The ideWhile alcohol and group drinking can work to maintain and confirm group cohesion, it also can operate in a divisive manner . These iFew researchers have examined the interconnections between two endemic features of gang life: violence and drinking. To date, most gang researchers have focused on violence and its relationship to illicit drugs and have largely neglected the importance of alcohol in gang life. This article provides a brief review of the extent to which drinking is a pervasive feature of gang life and the ways in which drinking connects with different types and settings of violent behavior.In focusing on drinking and violence among youth gangs, researchers can begin to explore the social processes that occur in the development of violent behavior after drinking . This fo


Cephalorhynchus hectori) and little penguins (Eudyptula minor). The relative abundance of the two predator species during surveys was modelled according to the relative abundance of potential prey using generalised additive mixed models. Schools of epipelagic fish were readily detected by the RGE system and were more abundant in summer compared to winter. The models performed well, explaining 43% and 37% of the deviance in relative abundances of dolphins and penguins respectively. This is the first study to link the distribution of Hector’s dolphin to that of their epipelagic prey and confirms the utility of RGE in studies of habitat use in marine predators. Limitations associated with a lack of formal acoustic calibration and data formatting can be overcome and would make RGE valuable, inexpensive tools for investigating variability in populations of small pelagic fishes.Quantifying the distribution of prey greatly improves models of habitat use by marine predators and can assist in determining threats to both predators and prey. Small epipelagic fishes are important prey for many predators yet their distribution is difficult to quantify due to extreme patchiness. This study explores the use of recreational grade echosounders (RGE) to quantify school characteristics of epipelagic fish and link their distribution to that of their predators at Banks Peninsula, New Zealand. The hydro-acoustic system was ground-truthed with 259 schools of epipelagic fish. During 2015 and 2016, 136 hydro-acoustic surveys were conducted with concurrent observations of Hector’s dolphin ( The distribution of marine top predators generally reflects that of their prey –3. For tPatchiness over multiple temporal and spatial scales ,5,13, isFor many research programmes the significant cost involved with the purchase or hire of a scientific echo-sounder (SES), and the expertise or logistic requirements to operate such equipment, present major hurdles. These factors may compromise the repeatability of surveys and therefore constrain the sample size required to resolve a patchy prey field. Several modern recreational grade echo-sounders (RGE) allow on-board recording of the digital acoustic data, and could, within certain limitations, provide an alternative to SES. RGEs have been used to quantify aspects of the prey community in deep water habitats  and coasLittle is known about the distribution of epipelagic schooling fish in New Zealand waters, particularly at the fine scales relevant to determine overlap with marine predators, see ,24–26 foCephalorhynchus hectori) is an endangered coastal dolphin that is found in shallow (<100m) waters around the South Island of New Zealand. Banks Peninsula is a stronghold for this endemic species. The dolphins have a generalist diet focussing on species throughout the water column, but epipelagic prey  contribute significantly to their diet )A final limitation is the small volume of water sampled for prey due to the narrowness of the beam in shallow water habitat. This is not a limitation of RGE per se, with SES facing similar challenges in shallow water ,71. WhenDespite these limitations, there was clearly a strong overlap between predators and potential prey in this study. This provides evidence that RGE can be used as a tool to investigate habitat-use in coastal predators. Distribution models for both predator species explained a good proportion of deviance in the response variable; comparable and in some cases exceeding those from other studies linking predator and prey distribution ,7,66,69.This is the first study to establish overlap between Hector’s dolphins and little penguins with their epipelagic prey. These predators have an endangered and threatened status, respectively ,74. SubsInternationally, there has been substantial concern about the state of stocks of small epipelagic fishes ,29,75. TS1 FigThe depth dependence of a mean backscatter values from selection of schools detected during predator-prey surveys is shown before (a) and after (b) correction.(TIF)Click here for additional data file.S1 FileThe file contains datasets for the ground-truthing exercise and the predator-prey surveys.(ZIP)Click here for additional data file.


To explore the attitude and vision of midwives, anaesthesiologists, and obstetricians concerning a dedicated operating room for cesarean sections within the delivery ward versus cesarean sections within the general operating room. A descriptive qualitative study using a constructive paradigm. Face-to-face semistructured interviews were performed in 3 different hospitals, one without operating theatre within the delivery ward, one with a recently built cesarean section room within the delivery ward, and one with a long time tradition of cesarean section in the delivery room. Interviews have been analysed thematically. Three themes have been identified: organization, role of the midwife, and safety. Although identical protocols for the degree of emergency of a cesarean section are used, infrastructure and daily practice differ between hospitals. Logistic support, medical and midwife staffing, and hospital infrastructure are systematically mentioned as needing improvement. Realizing cesarean section within the delivery ward was considered as an improvement for the patient's experience. Midwives need a clear and new job description and delineation and mention a lack of formal education to assist surgical procedures. To increase patient safety continuous education and communication are considered necessary. A detailed job description and education of all those involved in cesarean section at the delivery ward are necessary to improve patient safety. Patient experience is improved, but our knowledge on this is hampered by lack of studies. Cesarean section rate is rising all over the world . The proAn essential part of improving the experience of cesarean section consists in avoiding separation of mother and child including skin to skin contact immediately after birth in the operating theatre , 4. FredA dedicated operating room for cesarean section within the delivery ward can help implement continuous skin to skin contact and improve patient experience; such a specified cesarean section room is not connected to the main operating block . A speciThe place where delivery takes place influences not only the way the mother-to-be lives through this major life event, but also the attitude of midwives and thus should be taken into consideration when trying to improve the care given to parturient women . On the The aim of the current research is to analyse the views of midwives, obstetricians, and anaesthesiologists on performing cesarean sections outside the main operating block and in the delivery ward.We performed descriptive qualitative research using a constructive paradigm. The paradigm states that any person has his/her own views and interpretation of reality; no interpretation is considered superior to another. Face-to-face semistructured interviews were performed and recorded. The study population consisted of midwives, gynaecologists, and obstetricians from three hospitals in the region of Antwerp, Belgium. All 3 hospitals are comparable as to the number of deliveries, between 1500 and 2000 per year. The hospitals are different for the infrastructure related to a cesarean section room in the delivery ward. The first hospital  has a long-standing tradition of cesarean sections in the delivery room; the second hospital ) had started performing cesarean sections in a new operating theatre in the delivery suit 6 months before our study; the third hospital (Middelheimziekenhuis) has no operating theatre in the delivery room; all cesarean sections are performed in the main operating theatre. In every hospital at least one midwife, one anaesthesiologist, and one gynaecologist have been interviewed. Every interview followed a previously determined scenario including 3 topics: cesarean section, location, and working experience. Respondents in each hospital have been selected by sending an email to all midwives, obstetricians, and anaesthesiologists working at the obstetric department. Data collection was started in December 2016 and ended in April 2017. The scenario for the semistructured interviews included after presentation of the interviewer (JJ) a short explanation that the study aimed at describing the viewpoint of professionals regarding cesarean section within the delivery ward. First basic demographic questions were asked . Then the following were asked: what the local standard protocol for cesarean sections was and what the participant's personal experience with this was. In case an operating theatre was present in the delivery ward we questioned when it was used , and whether only sections were done or also other procedures. Next questions were on personal work experience considering advantages and disadvantages of this location, personal experience in cooperating with other disciplines, any other remark or recommendation one would like to make, and how the respondent thinks pregnant women and their family think about the location.All interviews were recorded electronically and coded. Analysis was based on a thematic approach. The interviews were transcribed and code book was developed. To avoid bias the first interview was coded not only by the researcher but also by an independent other; the code book was developed in consensus and is given in Ethical committees of each hospital have reviewed and approved this research. Written informed consent was obtained from each respondent before the interview.Qualitative thematic analysis resulted in three main themes see : organizFour anaesthesiologists, 3 obstetricians, and 3 midwives have been interviewed. Demographic data are listed in In both hospitals that perform cesarean sections in the delivery suit organization and location were similar. The dedicated cesarean section room is next to the delivery room and connected to a neonatal reanimation room. After cesarean section the patient is observed for one hour in a room with maternal monitoring. Cesarean sections are coded according to emergency degree by colours: red, orange, yellow, and green from highly urgent to elective. The system with colours is highly appreciated as it improves communication. Quote: “we have introduced this colour system as an urgent cesarean section was quite differently experienced by obstetricians versus anaesthesiologists; code red means immediately, that is clear for everyone, no delay” (an anesthesiologist). In the hospital that does not perform cesarean sections in the delivery ward, this was a specific choice because the anaesthesiologists considered it an unsafe practice.In every interview it was clear that medical and midwife staffing was crucial and difficult because it was not reported by the hospital. Quote: “first it was decided that a cesarean section room was going to be built in the new delivery ward, but then hospital management did not allow for extra midwives or anaesthesiologists” (a midwife). All respondents mentioned that extra staffing is necessary. Dedicated anaesthesiologists for the delivery ward are considered necessary especially in case of an emergency. Quote: “it should be possible to have an anaesthesiologist available all day and an extra midwife for planned an unplanned cesarean sections, but in our context this is financially impossible” (anaesthesiologist). The location of the obstetric department and the distance to the general operating block are considered crucial factors for patient safety. Quote: “in my opinion a cesarean section room can be organised autonomically but it should be localised next to the central operating block” (anaesthesiologist). On the other hand, others considered having an operating theatre within the maternity unit safer when the distance with a central operating block is long “I think in all hospitals with the distance between the maternity and operating block is more than 100 m, there should be an operating theatre within the maternity” (anaesthesiologist).All respondents consider a dedicated cesarean section room within the delivery ward as a positive experience for patient as mother and child are not separated and can stay together all the time; also the recovery period in which mother and child are often not together can be deleted; this improves skin-to-skin contact, first breastfeeding, and mother-child bounding. Quote: “all patients are happy, especially that they do not have to go to the recovery room and they are together with the baby continuously now, also the partner can stay with the baby and a woman all the time, patient is really appreciate that we perform cesarean sections here in our department” (a midwife). In the hospitals where it is not possible to perform a cesarean section in the delivery ward alternative ways to improve the experience are looked for; in the recovery room, an isolated space where the mother can stay with her baby was realized but financial limitations made it impossible for a midwife to stay with the mother.It is clear that midwives do not feel prepared from the formation to assist in operating theatre cesarean sections; in one of the hospitals where cesarean sections were only recently performed at the maternity unit, operating nurses were still assisting and this was considered as a source of frustration; obstetricians and anaesthesiologists know exactly what to do in the operating theatre; for the midwives this was a new experience and their exact job and responsibility was not clearly defined. Tension arises when an operating nurse enters the cesarean section room. Quote: “midwives are not nurses and have no experience with working in operating room, they have not received any formation for that and during interventions really feel the difference between an operating nurse and a midwife” (gynaecologist); “we need training more than we have received until now; if anything goes wrong I would not know what to do; I do not feel certainly enough to stand alone as a midwife in the operating together” (midwife). Midwives feel that it is difficult on one hand to be a technical person and assisting the anaesthesiologists or the obstetrician and on the other hand to be present for the parents and taking care of the baby. Training and communication are mentioned as highly important especially in emergency situations.Logistics are also considered of high importance; after each cesarean section all the materials should be checked and frequently discussions rise regarding who has to perform this; anaesthesiologists that are not used to working on the obstetric department mentioned that they feel unsafe in a room where they do not feel at home as in their usual operating theatre.From these interviews it becomes clear that introducing cesarean sections into the delivery ward makes it necessary that midwives receive extra training and formation to assist surgery as in Belgium, and most countries, a midwife is not a nurse. In general in the formation of midwives the physiology of labor and delivery is considered crucial; it can be questioned whether in a changing world it would not be better to train midwives systematically for assisting cesarean sections. The competencies that midwives should achieve are changing . ActuallAnaesthesiologists are much more critical when it comes to patient safety; midwives and obstetricians have more interest in the positive experience of the patient. This demonstrates the technical medical view of anaesthesiologists versus the more physiologic and normal medical view of midwives and obstetricians. To realize safety teamwork is of the utmost importance, especially in obstetric care . This caLiterature on dedicated cesarean section room within a delivery unit is scarce. Graham et al. describe the experience in an academic hospital where patients planned for elective cesarean experienced waiting times and difficulty in transport to the operating theatre . To imprKasagi et al. describe the start of an operating theatre in a perinatal unit, away from the central operating block, a situation comparable to the hospital as we describe in this paper . Before In our descriptive study the same limitations are mentioned: lack of staff and lack of training; also the same advantages are mentioned, especially the positive experience by the patient.Our study is limited by its quantitative and descriptive setup and by the small number of interviews. We do not know whether the opinions of anaesthesiologists, obstetricians, and midwives in our sample can be generalised but they do seem to be in the same line as what is published. We did not interview patients or family.Discussions on the safety of the concept of an isolated cesarean section room seem to be frequent between anaesthesiologists and obstetricians; it is remarkable that almost no studies are available –15.When introducing a dedicated operating room for cesarean sections within the delivery ward we recommend that this process be developed together with anesthesiologists and midwives from the very start. As concerns the midwives an intense coaching by trained operating nurses who progressively leave responsibility to the midwives is advised. A rotating period in which midwives do perform basic practice in the general operating room, in case this was lacking during basic training, is considered worthwhile. A dedicated team of obstetrics anesthesiologists would most probably be the ideal situation, but this can be difficult to realize in most centres. Anyhow involving anesthesiologists in the organization of the delivery ward operating theatre so they feel at ease with the location and material is necessary. Regular phantom training with the multidisciplinary team can also increase the ease of working.Advantages for the patient and family are often mentioned as arguments in favour of cesarean section within the delivery department; safety issues are unclear. Transposing surgery from the operating theatre to the delivery ward necessitates a new competency profile of the midwife. More systematic research on this subject is necessary to guide us further in the organization of obstetrics in hospitals.


Plasmodium malariae on the fourth LM in its pathognomonic “rosette” schizont  technique increased the identification of P. malariae that might have been misdiagnosed as fever of unknown origin.5 Although there were reports of late onset and recrudescent fever despite adherent chemoprophylaxis, subsequent treatment has been paradoxically successful with the same medication.6 Because of P. malariae’s long senescent periods, recrudescent ability, and low parasite burden, clinicians must have high clinical suspicion and consider repeating LM when resource is limited or using PCR for diagnosis.7A 31-year-old previously healthy male required hospital admission after returning from rural Cameroon 10 weeks prior with severe myalgia, chills, 72 hours cyclical fever to 103.1°F, and tachycardia for 2 weeks. He endorsed adherence to atovoquone/proguanil chemoprophylaxis and recalled no exposure to lake or stream water. He was ill appearing, but without focal abnormalities. Laboratory findings were significant for leukopenia 2,900 cells/uL, thrombocytopenia 82,000 cells/uL, aspartate aminotranferase 316 units/L, and alanine aminotransferase 400 units/L. Initial three light microscopy (LM) and rapid diagnostic test (RDT) with BinaxNOW  were negative. However, continued investigation eventually revealed schizont  and “banschizont .1 The pa


Drinking and driving has been identified as one of the most important contributors of motor vehicle fatalities. This paper addressed the existing gap in our public health knowledge regarding the current prevalence of driving after drinking and how this has changed over the past decade.Prevalence rates of drinking and driving in 2001–2002, and changes in those prevalence rates between 1991–1992 and 2001–2002, were examined in two large nationally representative surveys of the U.S. population.Overall, the prevalence of driving after drinking was 2.9 percent in 2001–2002, representing approximately six million U.S. adults. This rate was about three-quarters of the rate observed in 1991–1992 (3.7 percent), reflecting a 22-percent reduction. Generally, the male–female differentials in the rate of driving after drinking decreased over the past decade. However, the sex ratios increased substantially for underaged youth over the past decade, reflecting the sharp decrease in prevalence of driving after drinking among 18- to 20-year-old women. Constant and emerging subgroups at high risk for drinking and driving included Whites, Native Americans, males, underaged young adults, and 21- to 25-year-olds.The results of this study highlighted the need to continue to monitor prevalence and changes in driving after drinking. Results are discussed in the context of strengthening existing prevention and intervention efforts and developing new programs with the sociodemographic differentials observed in this study in mind. Road traffic injuries and fatalities are a global problem affecting all sectors of society. The World Health Organization (WHO) predicted that 1.39 million people would die in road traffic crashes in 2000 and that 2.34 million people will die in 2020 . Among tThe practice of drinking and driving has been consistently identified as one of the strongest predictors of motor vehicle fatalities worldwide . In the The National Highway Traffic Safety Administration (NHTSA) maintains the Fatal Accident Reporting System (FARS), which collects detailed information for every fatal traffic crash occurring in the United States. Yearly data are released for public use by the following year and have been used to identify demographic and drinking characteristics associated with a high risk of fatal injuries e.g., . FARS daThe Behavioral Risk Factor Surveillance System (BRFSS) is a nationwide annual telephone survey of U.S. adults that has also collected data on drinking–driving in addition to other health-related behaviors. As evidence indicates that automobile fatalities are the leading cause of death among American youth 15–20 years old , numerouNIAAA, 1993From a review of previous research, it became apparent that few studies provided prevalence information on alcohol-impaired driving at the national level or within important subgroups of the population. Nor did many of the studies track changes in the prevalence of alcohol-impaired driving over time within major subgroups of the population. From a public health policy standpoint, it is essential to be able to assess the prevalence of driving after drinking too much, along with changes of the prevalence over time both at the national level and within major subgroups of the population. In light of the bold national goal established in 1995 to reduce alcohol-related automobile crash fatalities to 11,000 by 2005 , the pron = 42,862) and the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions .The purpose of this paper, therefore, was to address the existing gap in the public health knowledge regarding the 12-month (current) prevalence and changes in drinking and driving over the past decade among important subgroups of the U.S. population. To address changes in drinking-and-driving practices, we compared data from two large nationally representative samples of the U.S. population: the 1991–1992 National Longitudinal Alcohol Epidemiologic Survey  of the United States conducted by the National Institute on Alcohol Abuse and Alcoholism. Details of these two surveys have been described in detail elsewhere , 2003. FTo ensure adequate numbers of respondents for analytic purposes, over-sampling of Blacks in NLAES and of Blacks and Hispanics in NESARC was implemented at the design phase. Within each household unit, a person age 18 or older was randomly selected. Young adults (ages 18–29 in NLAES and ages 18–24 in NESARC) were oversampled at a rate of 2.25:1.00 at this stage of sample selection to secure a greater representation of this heavier drinking subgroup of the population. Both samples were weighted to adjust for oversampling young adults and nonresponse at the household and person levels. The data were then adjusted to be representative of the U.S. population for a variety of socioeconomic variables including region, sex, race, and ethnicity using the 2000 Decennial Census.On NESARC, driving after drinking was explored by asking “In your entire life, did you EVER more than once drive a car, motorcycle, truck, boat, or other vehicle after having too much to drink?” A followup question, “Did that happen in the past 12 months?” was asked if the answer to the preceding question was “yes.” There was a slight variation in the question on the NLAES survey, in which the question read, “In the last 12 months, did you drive a car, motorcycle, truck, boat, or other vehicle after having too much to drink?” A followup question—“About how many times did this happen in the last 12 months?”—was asked if the answer to the preceding question was “yes.” To equate these measures, only NLAES respondents reporting driving after having too much to drink more than once were included in the analyses presented here.ttests designed for independent samples.To account for the complex sampling design of both NLAES and NESARC, a specialized software program, SUDAAN , was useThe 12-month prevalence rates of driving after drinking by age, sex, and race are presented in p < 0.001). When examined within the race–ethnicity and sex groups, the prevalence of driving after drinking was significantly (p < 0.001) greater among young adults (ages 18–29) compared with the rates of all other age groups, but only among White males.Young adults ages 18–29 (5.3 percent) were significantly more likely to drive after drinking in the last 12 months, compared with 30- to 44-year-olds (3.5 percent) and 45- to 64-year-olds (1.9 percent), with age differentials of 1.5 and 2.8, respectively. Respondents age 65 or older had the lowest prevalence of operating a motor vehicle after drinking  greater than those of Blacks (1.5 percent), Asians (1.4 percent), and Hispanics (2.1 percent). Notably, the rates of the latter three ethnic groups did not significantly differ. When prevalence was examined with respect to gender, significantly greater rates were observed among Native Americans relative to Whites, Blacks, Asians, and Hispanics, and this difference was statistically significant among males and females.Native Americans exhibited the highest rate of driving after drinking (4.1 percent), which was significantly , a ratio of about 2:93. Among race–ethnic groups, however, we observed no gender difference among Native Americans and Asians. In contrast, males showed significantly greater rates than females among the other ethnic groups . The sex ratios varied from 2:9 to 3:7 for these three ethnic groups.Gender differences were observed within age–ethnicity subgroups of the population. In general, males were significantly more likely to drive after drinking compared with females for most age groups among Whites, Blacks, and Hispanics. Due to several prevalence rates not meeting precision standards, we were not able to assess the gender differences among the age–ethnic subgroups of Native Americans and Asians.To address the elevated prevalence of driving after drinking among the young adult group (18- to 29-year-olds) we disaggregated this age category into single ages and present the prevalences and associated population estimates by sex in In the total sample, the prevalence of driving after drinking significantly declined 22 percent over the past decade, from 3.7 percent to 2.9 percent . SignifiAmong males, significant decreases in the rates of driving after drinking were observed among Whites overall (6.4 percent versus 5.0 percent), Hispanics overall (5.4 percent versus 3.3 percent), and among 18- to 29-year-old males (11.6 percent versus 7.8 percent), 18- to 29-year-old Whites (13.9 percent versus 9.9 percent), and 18- to 29-year-old Hispanics (8.8 percent versus 5.0 percent).The picture was different for females. Significant reductions in the rates of driving after drinking were noted for 18- to 29-year-old females overall (4.2 percent versus 2.9 percent) and 30- to 44-year-old Black females (1.5 percent versus 0.4 percent) over the last decade. In contrast, small but significant increases in the corresponding rates were observed among females ages 45–64 (0.4 percent versus 0.9 percent) and among 18- to 29-year-old Hispanic females (0.6 percent versus 2.0 percent).To further examine changes in driving after drinking among 18- to 29-year-olds, we disaggregated age into 1-year intervals for that age group . In the This paper examined the prevalence of driving after drinking, which is identified as one of the major contributors to automobile crash risk and subsequent injury and premature death. A variety of deterrence-based initiatives have been introduced and implemented during the past decade. A significant and concurrent reduction has been observed in rates of drinking–driving and alcohol-related automobile crashes in most developed countries. In 1982, there were 26,173 alcohol-related fatalities in the United States. By 2002, alcohol-related fatalities fell to 17,419, representing a 33.4-percent reduction . Our resNIAAA, 1993The decrease in driving after drinking varied across major sociodemographic subgroups of the population. Overall, there was a decrease in the gender difference in prevalence of driving after drinking over the last decade (the sex ratio decreased from 3:41 to 2:93). This male–female convergence was partly due to a greater reduction in prevalence among White and Hispanic males than among their female counterparts. Furthermore, White middle-aged females (ages 45–64) and Hispanic young adult females showed significant increases in prevalence over the past decade, causing the gender gap to diminish even further. Echoing this narrowing gender gap, detailed analyses on drivers using the FARS data over the same time period revealed that among all alcohol-related fatal crashes, the male-to-female ratio in alcohol-related fatal crashes dropped from 9 in 1991 to about 5.4 in 2001 , 2003.This convergence in male and female prevalence rates was further examined with respect to individual ages among the young adult age group, where our detailed analysis showed contradictory results. Most significantly, sex ratios in fact increased substantially for under-aged youth (ages 18–20) over the past decade, reflecting the sharp decrease in prevalence among 18- to 20-year-old women. This finding demonstrates how aggregating age groups can have a significant impact on study results and their implications. This is especially true with respect to drinking and driving, because crash risks are highest at the extremes of the age spectrum . It is nDespite long-standing prevention and intervention efforts, our results showed that drinking–driving remained prevalent among young adult males (7.8 percent) in 2001–2002 even though the rate had decreased since 1991–1992 (11.6 percent). Our detailed analysis further showed that about 1 in 10 young adult males ages 22 and 23  posed significant risk on the roadways because of their hazardous driving practices. The vulnerability of young adults is consistent with previous findings that being young and being male are strong demographic correlates of drinking and driving . It is aAmong young adult males between 18 and 29 years old, White youth were at the greatest risk (9.9 percent) for driving after drinking. This rate was substantially greater than those of their Black, Asian, and Hispanic counterparts, consistent with earlier studies showing that the prevalence of drinking and driving among young minority groups is lower than that of Whites . In the In any research when data regarding a socially unacceptable behavior such as driving after drinking are assessed, the prevalence tends to be underestimated. With respect to this “social undesirability bias,” it has been suggested that these self-reported measures gathered with well-designed surveys can, nonetheless, be useful, even essential tools, for assessing individual-level epidemiological relationships . Thus, oIn summary, the availability of the NLAES and NESARC data obtained 10 years apart allows constant and emerging high-risk subgroups of the population with respect to driving and drinking to be identified with much greater clarity and specificity than in the past. Whites, Native Americans, males, and 18- to 29-year-olds demonstrated the highest rates of driving and drinking in 1991–1992, rates that have remained consistently high in 2001–2002, despite decreases in rates during that time period. Emerging risk subgroups of the population include 45- to 64-year-olds and 18- to 29-year-old Hispanic females, who demonstrated small but significant increases in the rate of driving after drinking over the past decade. However, our detailed age analyses for young adults identified most underage young adults (ages 18–20) and young adults ages 21–25 at high risk of driving after drinking, as evidenced by the stability in rates among these younger age groups over the past 10 years. Taken together, these results highlight the need to strengthen existing prevention and intervention efforts and to develop new programs designed with these sociodemographic differentials in mind.Most countries worldwide experienced declines in automobile crashes and traffic fatalities in the early 1980s and 1990s. The progress in reducing mortality from road traffic injury in many countries has since stalled or even reversed . Despite


Alcohol consumption among Indigenous Australians can be irregular, depending on social and geographic context. The Finnish method uses the last four drinking occasions to estimate drinking quantity and pattern. The Grog Survey App is an interactive and visual tablet computer application which uses touch-screen technology to deliver questions on drinking.Alcohol consumption recorded on the Grog Survey App using the last four occasions (Finnish) method was compared with a clinical interview conducted by an Indigenous Australian health professional. To assess convergent validity, Spearman’s ranked correlations between consumption estimates from the App and from interview were calculated. Sensitivity and specificity analyses were used to compare how well the App and clinical interview agreed when classifying drinkers’ risk. To assess criterion validity, average grams alcohol per day as estimated by the App (and by interview) were compared against presence of self-reported withdrawal tremors (from App or interview). Test–retest reliability was assessed by correlations between measures of alcohol consumption recorded on two occasions.The App recorded higher numbers of standard drinks consumed per drinking occasion than the interview. There was reasonable agreement between the App and interview across common reference periods . Average consumption recorded by the App was as good or better predictor of withdrawal tremors than consumption as estimated by interview.The Finnish method, as delivered by the App, offers an innovative way to collect survey data on alcohol in a population with an intermittent drinking pattern. Alcohol is consistently reported as a key concern for Aboriginal and Torres Strait Islander (Indigenous) peoples in Australia , 2 and fA range of survey items have been used to assess alcohol consumption in general populations. Most include an assessment of the overall frequency of drinking and the usual quantity consumed on each occasion (quantity-frequency), or alternatively, how often certain amounts of alcohol are consumed on a weekly or monthly basis (graduated-frequency) . Both meMost of these approaches to assessing drinking ask participants to describe their consumption in ‘standard’ drinks , requiriThere is a lack of validated tools to assess alcohol consumption in Australia’s Indigenous peoples, or in similarly colonised peoples . It is unclear whether tools validated for non-Indigenous settings are suitable in these contexts , 14. A sA number of shorter screens for risky drinking have been used among Indigenous Australians, including the first three (consumption) questions of the Alcohol Use Disorders Identification Test (AUDIT-C) , 18. HowIn any population, collecting reliable self-report data on alcohol use is complex given the potential sensitivity of this topic. These concerns can be greater among Indigenous populations because of experience of racism, fear of consequences of admitting to heavy drinking, and shame over harms from drinking . For allThe Grog Survey App [the App] was developed in response to the need for an easy-to-use tool to help Indigenous Australians report on their drinking in a household survey environment . “Grog” Study methods were designed by investigators in consultation with the Aboriginal Drug and Alcohol Council of South Australia; the Aboriginal Drug and Alcohol Network, representing Aboriginal alcohol and other drug workers in NSW; and the Aboriginal Health Council of South Australia (AHCSA), the peak body for ACCHSs in South Australia (SA). Ethical approval was obtained from ACHSA and from the Metro South Health Human Research Ethics Committee in Queensland.r = 0.8, and ɑ = .05 a sample size of 46 is required . Greater sizes were sought to try to allow analysis of differences between urban and remote sites in sampling, and because of anticipated challenges in ensuring complete data collection. In urban Queensland (Qld), recruitment was based in an Indigenous primary health care service and surrounding community. In South Australia (SA), recruitment centred on a regional ACCHS and a remote Aboriginal community-controlled drug and alcohol day centre (a drop-in service). Individuals were eligible for inclusion if they self-identified as being Aboriginal or Torres Strait Islander and were 16+ years. Exclusion criteria included obvious intoxication. Participants were reimbursed for their time and travel expenses with a store voucher.To assess the validity of the Finnish method as delivered by the App with a range of drinkers, stratified sampling was used. We aimed to recruit: 20 non-drinkers, 40 non-dependent drinkers and 40 dependent drinkers in each of two states by word-of-mouth in each service. Most of the analyses involved in validating and shortening the scale used in the pilot study require little statistical power. For instance, for the reliability analysis, in order to have sufficient power (80%) to identify a correlation of 0.4 where Each participant also took part in a semi-structured clinical interview, typically within 2–7 days of completing the App. We set out to have half the participants complete the App before the interview, and half afterwards. To assess the test–retest reliability of App responses, participants were asked to complete the App twice within 2–7 days.The development of the App and selection of its survey items have been described elsewhere . BroadlyAlcohol consumptionThe App ‘reads out’ the questions in English or in Pitjantjatjara . The App was designed to take no longer than 20 min to complete. Aboriginal field research assistants handed the tablet computer to participants, with brief guidance, then stood to one side, in case there were any challenges. Individuals with no prior computer contact were able to use the App without assistance . The AppAlcohol withdrawal tremors (‘grog shakes’)Using an adaptation of the Finnish method of assessing drinking, the App asks respondents to show the date of their four most recent drinking occasions within the last twelve months. Participants are then asked how much alcohol they consumed on each of these occasions. Participants select pictures of the type of alcohol, the container they drank it out of, and how full the container was with alcohol . The AppParticipants were asked: “Some people’s hands shake when they stop drinking or before their first drink of the day. How often does this happen to you?” Responses were indicated on a five-point Likert scale ranging from ‘never’ to ‘most days or every day’.Data collection for the survey App was facilitated by five Aboriginal research assistants  who were either Aboriginal health workers  or AboriThe clinical interview was conducted by two female Aboriginal health professionals (one in each state), each with knowledge of local culture, context and language. In keeping with past research with Aboriginal respondents , this waConsistent with local clinical practice, the interviewer assessment of drinking focused on the past 14 days. Notes on drinking quantity were recorded on a 2-week calendar showing the days of the week (from Monday to Sunday in each row) so that the client could look along with the interviewer. The approach used was similar to the Timeline Followback . If no dOn each drinking day, the interviewer recorded ‘longhand’ what the participant drank, for example, “two longnecks of West End”, which is the local term for 2 × 750 mL bottles of a brand of full-strength beer. To maximise participant engagement and to keep the interview short, interviewers did not convert responses to Australian standard drinks (10 g ethanol). This was later done by a research assistant (TW).Interviewers also assessed dependence, by asking current drinkers if they experienced tremors when they stop drinking or cut down. Clarification on the interviewers’ clinical notes was sought by one author (KC) if needed. Data entry was conducted by a research assistant.Standard drinks were calculated by the App itself. All other analyses were performed in the R statistical programming language . As therThe mean number of standard drinks that participants consumed on drinking occasions was calculated by taking the average of the number of standard drinks consumed on the most recent four drinking occasions. The last four occasions (Finnish) method of assessing consumption does not use a fixed reference period. Non-drinking days are recorded between the interview and most recent occasion. However, necessarily, the reference period ends with the fourth most recent drinking occasion. On average, this results in over-estimates of drinking frequency. To reduce this bias, for each individual, we extended the reference time period by adding half of the average gap between their drinking occasions to their reference period. To calculate the frequency of drinking occasions, the total number of recorded occasions was then divided by the total reference period (in days). To calculate average daily consumption, we multiplied the average quantity each individual consumed per occasion, by their frequency of drinking occasions.Following data cleaning, estimates of alcohol consumption by the last four occasions method were compared to estimates from the clinical interview. We examined the correlation between the two estimates of both drinking intensity (drinks per drinking occasion) and average daily consumption for each person.Sensitivity and specificity were calculated to compare the extent to which the App agreed with the clinical interview when classifying drinkers’ risk . The clShort-term risk from drinking was defined as consumption of more than four drinks on any occasion . Long-teComparisons of App and interview consumption initially considered all recorded drinking data. However, because the clinical interview focused on the last 7–29 days while the App collected data on four occasions which could be spread across the year, comparisons were then repeated using only those days which were examined by both the App and interview. To account for differences in participants’ recall of when these occasions occurred, a buffer of 3 days was included. For example, if a date logged in the App occurred within 3 days of a date in the corresponding clinical interview (whether consumption was zero or higher), it was included in the analyses. The median number of matched days was 23.5. All participants had one or more matched days.A total of 238 participants completed both the App and clinical interview. Of these, 32 cases were excluded because the hand-recorded information required to match the individuals’ interview and App responses was incomplete or incorrect . Most of these cases were from a remote location where external events disrupted the pen-and-paper participant registration. After exclusions the final sample size was 206 participants.Twelve participants reported drinking more than 100 Australian standard drinks on a single occasion on the App. These quantities seem unlikely . However, as we are using non-parametric analytic methods the influence of outliers is minimal. Accordingly, these cases were included in the analyses initially, then analyses repeated with them excluded.p > .9; calculations used app data, these relationships were also non-significant using interview data).Just over half 51.9%) of the sample were male. Ages ranged from 18 to 78 years . Almost half (47.6%) of the sample were from urban areas; 16.5% from regional, and more than a third (35.6%) from remote areas  were identified as having consumed alcohol in the last 12 months by both the App and interview. The App identified more participants as drinkers than the interview—80.6% (n = 166) and 76.2% (n = 157) respectively. Interviewers recorded at least 14 days of drinking data for 86.5% of drinking participants. For the majority of drinkers (75.4%), the Grog App covered a reference period equal to, or longer than the clinical interview.median = 14.8, IQR = ; median = 14.0, IQR = ; respectively, matched reference periods). On the App, males and female drinkers recorded a similar median number of standard drinks per occasion . In the interview, male drinkers reported a higher median number of standard drinks per occasion than female drinkers .The App tended to record a higher median number of standard drinks per drinking occasion than the clinical interview . The greatest number of standard drinks consumed on a single occasion for each participant also tended to be higher for the App than for the interview  per participant compared with one  for the interview. In keeping with this, nearly one in five  of those who reported consuming any alcohol in the last 12 months on the App did not report any drinking occasions during the four-week retrospective diary. All of these participants recorded at least one drinking occasion on the App.Across all data, drinkers on the App recorded a median of four drinking occasions .Because most drinkers were not daily drinkers, despite high drinks per drinking day, average daily consumption was low. The recorded average consumption was slightly higher on the App than on clinical interview . Correlations were greater when only data from matched time periods were used (r = .62) Table .Table 3CThe App appeared to be highly sensitive in detecting at risk drinkers, as identified by the clinical interview, across all risk categories. The App detected 37 more risky drinkers than the interview if time periods were not matched. However, when only common reference periods were used the App identified only 10 more people at risk. This corresponded to an improvement in both sensitivity and specificity. Across all risk categories, when all data from drinkers was used, the sensitivity was 97.5% and the specificity was 10.8%; . When common reference periods were used, across all risk categories, the sensitivity was 92.7% and the specificity was 69.7% . The sensitivity and specificity for each risk category is presented in Table , respects = 0.48).To assess criterion validity of the App’s estimate of alcohol consumption, we compared average daily consumption measured by the App (and by the interview) with the presence of withdrawal tremors, as recorded on either the App or interview. Participants were more likely to report the presence of tremors when using the App than when responding to the interview .Average consumption recorded by the App was as good or better a predictor of withdrawal tremors than was consumption recorded by the interview Table . This waIQR = ) between administrations (range 1–51 days). Almost eight out of 10  participants completed the App twice within a week. Average consumption was well correlated across the two App administrations .In total, 194 participants completed the App twice, with a median of three days . When time periods were matched, the App also had good specificity compared with the clinical interview for long-term risk . Low specificity for short-term risk  is likely to be due to the longer reference period (up to 12 months) in those who completed the App compared with those who completed a clinical interview (2–4 weeks). Consumption as estimated by the App appears well correlated with alcohol withdrawal tremors. This suggests both internal consistency (in the case of within-App comparison), and criterion validity . Test re-test reliability was also good, particularly given that consumption may vary from day-to-day.The App recorded higher median consumption per drinking occasion than the retrospective diary did in the clinical interview, even when examining matched time periods. There are a number of reasons that suggest that the higher prevalence of risky drinking estimated by the App may be more accurate than the clinical interview. Firstly, this is consistent with the high prevalence of alcohol-related harms observed in Indigenous Australians . SecondlThe longer reporting period offered by the last four occasions method, as delivered on the App, compared with interview allows greater ability to detect infrequent, irregular, episodic drinking that is still high quantity. This pattern is common in this population . A standThere are similarities between the Finnish method as delivered on the App and paper-and-pen survey tools previously used to record detailed alcohol consumption in Indigenous Australians in remote WA  and non-The App also has similarities with an approach developed in Thailand to measure alcohol consumption that varies with cultural or other holiday periods in Thailand—the context-specific quantity-frequency method .Computer administration means that separate data entry of responses is not required, which reduces opportunity for human error. Computer administration also takes away the need for participants or interviewers to follow complicated survey instructions . Audio recordings enable standardisation of verbal presentation of questions.Just a small proportion (an estimated 10%) of individuals approached declined to take part in the study. However, reasons for refusal were not systematically collected.We chose to compare the App to a clinical interview. However, there is no perfect ‘gold standard’ against which the App can be compared. We cannot assume a mainstream gold standard, such as CIDI-SAM  will be The clinical assessment against which the App was compared included a 2–4 week retrospective diary. Retrospective diaries are commonly used to assess Aboriginal and Torres Strait Islander drinking patterns in clinical practice and in research. In research settings shorter reference periods are often used to shorten interview time, or to avoid over-reliance on memory. In this sample, the Grog App reported that several participants only drank a few times a year . As a result, the 2–4 week retrospective diary recorded during the clinical interview, would not have adequately captured the drinking patterns of those who had not regularly consumed alcohol over that time period.To adjust for this limitation, our sub-analyses were restricted to data from the App which was recorded in the same reference periods as recorded in the clinical interview. While this resulted in data-loss, as expected, it greatly improved sensitivity and specificity of the Grog App compared to the retrospective diary. This finding is relevant to researchers and clinicians, indicating that in samples with irregular drinking, detection of risky drinking may become less reliable with shorter reference periods. In future research it will be useful to compare the findings of the Grog App to instruments which may be better able to capture irregular drinking patterns. One potential example is AUDIT-C, though as discussed earlier, most response categories on this instrument assume some regularity of drinking.Despite using stratified sampling, the research assistants were only able to recruit small numbers of drinkers who were drinking within recommended limits. It would be good to repeat this validation with a sample with a greater range of drinking patterns. For example, a sample with higher socio-economic stratum, may have a greater range of drinking patterns .Fourteen individuals reported what we considered unrealistically high amounts per drinking occasion (100 + standard drinks) on the App. On clinical interview, all of these individuals were classified at short-term risk (median of 22.5 standard drinks per drinking occasion) and 79% at long-term risk from drinking. While it is not clear why these individuals reported drinking such high amounts on the App, repeating the analysis with their exclusion did not greatly change results.Future research could use additional sources of validation as set out in the LEAD paradigm , such as longitudinal data on which drinkers experience harms over the coming months or years . Use of This survey tool is likely to be valuable not just for Indigenous Australians, but in other contexts, such as developing countries, where alcohol is consumed in non-standard containers or episodically. Even for general populations, the visual interface provided by the App greatly simplifies reporting, regardless of comfort with writing or numbers. The tablet-computer platform is likely to save errors in data recording and data entry . This isThere has been considerable interest from Aboriginal and Torres Strait Islander primary healthcare services to use the App as a screening tool while clients wait to be seen by their health professional. Next steps are to refine the App based on suggestions received during the testing phase. Then the practical feasibility of the App as a survey tool will be examined. Further research on shortened versions to use as clinical screening tools will also occur. The survey App will be made available as a private iPad download from the ‘App Store’ initially, to ensure ongoing quality control. Features in this refined version will include options for individuals to generate a summary report on their answers . It will also include a feature for communities to collect their own Grog App data, and to generate a community-level summary report on drinking in their community.The Finnish method of assessing drinking as delivered on the Grog Survey App is the first approach to be formally tested for collecting a detailed assessment of alcohol consumption in Indigenous Australians, and possibly in Indigenous peoples worldwide. The last four occasions method appears to better cater for episodic and irregular drinking than a retrospective diary . The visual and interactive interface of the App is likely to assist with accuracy and comfort with reporting drinking, regardless of literacy or numeracy. This household survey tool is likely to be of interest to researchers, communities, health services and policy-makers seeking to assess alcohol consumption in vulnerable and marginalised populations worldwide.