We examined public knowledge and use of UK drinking guidelines just before new guidelines were released (2016). Despite previous guidelines being in place for two decades, only one in four drinkers accurately estimated these, with even fewer using guidelines to monitor drinking. Approximately 8% of drinkers overestimated maximum daily limits. Promotion of lower risk drinking guidelines is a commonly used public health intervention with various purposes, including communicating alcohol consumption risks, informing drinkers’ decision-making and, potentially, changing behaviour. UK drinking guidelines were revised in 2016. To inform potential promotion of the new guidelines, we aimed to examine public knowledge and use of the previous drinking guidelines, including by population subgroup.self-reported knowledge and use of drinking guidelines. Multinomial logistic regression examined the same set of variables in relation to accurate knowledge of drinking guidelines .A demographically representative, cross-sectional online survey of 2100 adults living in England in July 2015 (i.e. two decades after adoption of previous guidelines and prior to introduction of new guidelines). Univariate and multivariate logistic regressions examined associations between demographic variables, alcohol consumption (AUDIT-C), smoking, and knowledge of health conditions and In total, 37.8% of drinkers self-reported knowing their own-gender drinking guideline, of whom 66.2% gave an accurate estimate. Compared to accurate estimation, underestimation was associated with male gender, lower education and AUDIT-C score, while overestimation was associated with smoking. Few (20.8%) reported using guidelines to monitor drinking at least sometimes. Drinking guideline use was associated with higher education, overestimating guidelines and lower AUDIT-C. Correctly endorsing a greater number of health conditions as alcohol-related was associated with self-reported knowledge of guidelines, but was not consistently associated with accurate estimation or use to monitor drinking.Two decades after their introduction, previous UK drinking guidelines were not well known or used by current drinkers. Those who reported using them tended to overestimate recommended daily limits.We examined public knowledge and use of UK drinking guidelines just before new guidelines were released (2016). Despite previous guidelines being in place for two decades, only one in four drinkers accurately estimated these, with even fewer using guidelines to monitor drinking. Approximately 8% of drinkers overestimated maximum daily limits. In an effort to curtail the negative health, economic, and social effects associated with alcohol use, governments the world over seek to implement strategies to reduce alcohol consumption. Drinking guidelines are a public health intervention implemented in many countries, including the UK, with the intention of encouraging low to moderate alcohol use and informing the public’s decision-making around alcohol . GuideliIn comparison to other interventions intended to reduce alcohol consumption and related harms, such as increased prices and reduced availability, there is a paucity of evidence regarding the effectiveness of drinking guidelines , there aThe rationale of ‘informed choice’ is reflected by the current UK Alcohol Strategy which identifies drinking guidelines as a potential mechanism by which to ‘ensure that everyone understands the risks around excessive alcohol consumption to help them make the right choices for themselves and their families’, p. 5. AThe report of a monthly omnibus household survey provided data on guidelines knowledge, awareness and use among the general population of Great Britain from 1997 to 2009 in 10 waves . In 2009Given the recent release of new UK drinking guidelines, it is timely to once more consider levels of public knowledge of the 1995 guidelines , in orden = 5929) clicked the ‘Start your survey’ link. After screening for quotas based on the population distribution of gender, age, region and education for England, 42% (n = 2480) were eligible to proceed. Following exclusion of 380 respondents who provided incomplete or invalid responses, a final sample of 2100 was obtained (84.7% of those who commenced survey). Ethical approval for the survey was granted by the School of Health and Related Research Ethics Committee, University of Sheffield.In July 2015, a cross-sectional online survey was conducted to examine alcohol-related health knowledge, policy attitudes and consumption behaviour. Vision One, an independent market research company was used to recruit a sample of 2100 adults aged 18 and over. E-mail invitations to participate in a survey about ‘health and lifestyle behaviours’ were sent to 11,846 members of the market research company’s online panel, of whom 50%  variable self-reported guideline knowledge was created to reflect whether men and women knew their own gender guidelines.Knowledge of official drinking guidelines that were in place at the time of the survey was measured via two questions, ‘Do you know how many alcohol units it is recommended that accuracy of guideline knowledge: men who reported values between 3 and 4 units inclusive and women who reported values between 2 and 3 units inclusive for their own gender guideline were defined as having ‘accurate’ guideline knowledge, in contrast to those who provided an inaccurate estimate (‘underestimate’ = men <3 units/women <2 units and ‘overestimate’ = men >4 units/women >3 units). Those who were coded as ‘no’ for self-reported guideline knowledge above were not asked to indicate the recommended number of units and so were coded as ‘no estimate’ for the accuracy of guideline knowledge variable.Survey respondents who said ‘yes’ to knowing their own gender guideline were then asked to indicate the respective recommended amount onto a sliding scale . To assist in responding, a graphic was shown indicating the alcohol unit content of different types of alcohol in a variety of measures . Based on responses given on this scale, a new variable was created to indicate self-reported guideline knowledge) were also asked about the frequency of using it to keep track of their drinking . Responses were recoded into a new guideline use variable, dichotomized as ‘yes’  and ‘no’ (‘rarely’ or ‘never’).Respondents who reported knowing their own gender guideline . Postcode data were used to derive 2015 Index of Multiple Deprivation (IMD) quintiles . The IMDn = 250) from all analyses, yielding an analytical sample of 1850 drinkers. This sample was used to examine predictors of two outcome measures: self-reported guideline knowledge (yes/no) and accuracy of guideline knowledge . A subsample was created comprising respondents who provided an estimate of their own gender drinking guideline (n = 699) and this was used to examine predictors of a third outcome measure: guideline use (yes/no). Predictors of self-reported guideline knowledge and guideline use were identified via univariate and multivariate logistic regression models while predictors of accurate guideline knowledge were identified via multinomial logistic regression.Descriptive statistics were generated for demographic variables: frequencies for categorical variables and means and standard deviations for continuous variables. Given our focus here on the use of drinking guidelines, we excluded non-drinkers  was included as an additional variable in predicting guideline use. Predictor variables were entered into logistic regression models using the using the default forced entry (i.e. single step) method in SPSS V.22.0 for Windows. As each of the predictor variables were of intuitive relevance to the outcome measures, all were entered into multivariate analyses , IMD quintile (five categories from most deprived to least deprived) and smoker status . Continuous predictor variables were age in years, AUDIT-C score (range 1–12), and the number of health conditions endorsed as resulting from drinking too much alcohol (range 0–6). analyses .Half the sample (50.3%) were male and the average age was 48 years ; 13% had no educational qualifications, 56% had educational qualifications below university degree level, and 31% were qualified at university degree level or above. The proportions in each population level IMD quintile from most deprived to least deprived were 22.6%, 22.4%, 20.3%, 17.0% and 17.7% (excluding 19 cases for whom postcode data to derive IMD were unavailable). Most respondents were low risk drinkers, the average AUDIT-C score was 4.7 , and 33% were daily or occasional smokers. The average number of health conditions endorsed as being related to alcohol consumption was 4.1 .n = 463) accurately estimated, 13.8% (n = 96) underestimated, and 20.1% (n = 140) overestimated the number of daily units within their gender’s drinking guideline. Just over half  of those who self-reported knowing their own gender guideline, whether or not they accurately estimated this, reported using the guideline at least sometimes to keep track of their drinking .In total, 699 (37.8%) of respondents self-reported knowing the recommended maximum daily number of alcohol units for their own gender . Of these, 66.2%  were being male, having a below degree level qualification  and having a lower AUDIT C score. The only significant predictor of overestimation compared to accurate estimation was being a current smoker.Multinomial logistic regression analysis including all predictor variables showed that compared to those who accurately estimated their own gender drinking guideline, those who re Table . PredictSelf-reported use of drinking guidelines was associated with a degree or higher level of education, overestimation of the guidelines and higher AUDIT-C scores at the univariate level Table  and thesIn the context of the publication of new UK lower risk weekly drinking guidelines, our findings regarding knowledge and use of the previous daily guidelines are relevant to those with an interest in or responsibility for their promotion. Despite the previous UK drinking guidelines being in place for 20 years  includi, suggestWe further identified characteristics significantly associated with those who think they know, actually do know, and use their own-gender drinking guidelines. Being female, better educated, able to identify more alcohol-related health conditions and consuming more alcohol (as measured by AUDIT C) were all significantly and positively associated with not only claiming to know the drinking guidelines, but also in providing an accurate correct gender-specific estimate of the recommended daily maximum number of units (as they were at the time this study was conducted) compared to not providing an estimate. The same variables, excepting identification of alcohol-related health conditions, were also associated with providing a correct guideline estimate compared to an underestimate. However, when those who claimed to know the guidelines were then asked whether or not they used them to self-monitor their own drinking, only having the highest level of education (i.e. degree or above) remained a positive predictor of guideline use, while unsurprisingly, those who drank at higher levels were significantly less likely to report using guidelines to keep track of their drinking. Unexpectedly, those who overestimated their own-gender guideline were 2.5 times more likely to report using it to keep track of their drinking than those who provided a correct estimate, suggesting there may be a risk that some people drink more than recommended, but on the erroneous assumption that they are consuming within the guideline thresholds. It is of interest to understand whether this issue is now even more pronounced for males since the announcement of new guidelines, which lowered the recommended limits for men. There did not appear to be any inequality in knowledge or use of guidelines according to social gradient as measured by IMD, age or smoking status.Our findings have relevance for the targeting of promotional activities around the new guidelines. The variable most strongly positively associated with knowledge and use of guidelines was level of education, which suggests that in promoting the new drinking guidelines, efforts should be made to ensure people with lower educational qualifications are an explicitly identified target audience. The new guidelines may be simpler to remember than the old ones because there are no gender-specific recommendations, a single number and less ambiguity around the meaning of ‘regular’. However, the fact that the recommended limits for men have changed to a greater degree than for women, when considered in conjunction with our finding that men were less likely than women to self-report knowing or to actually know the previous guidelines suggests that decisions regarding appropriate promotional avenues for the new guidelines should still take account of gender to ensure reach. That greater awareness of alcohol-related health conditions predicted self-reported knowledge of guidelines but not their use is also an important finding for those designing promotional strategies for the newly released guidelines. Consistent with research regarding the effectiveness of health promotion campaigns (Our study used an online survey methodology and those who opt to participate in such panels may differ from the general population in important ways that we are unable to detect. However, our robust method of quota sampling with additional adjustment through weighting to improve representation related to education has ensured a nationally representative sample with respect to core socio-demographic variables. Levels of survey uptake and completion were also positive for this type of study. A commonly faced alcohol research problem is the potential for inaccuracies in self-reported alcohol use, whether by social desirability or incorrect understanding of what is meant by an alcohol ‘unit’ . To addrThe low levels of knowledge of previous guidelines found in this study suggest plenty of scope to increase public awareness. Teaching drinkers with unit-marked glasses was found to increase their understanding of guidelines but not alter their consumption (Twenty years after their introduction in 1995, only a minority of people in England could accurately estimate the UK drinking guidelines, and even fewer used them for the purpose of monitoring their own alcohol consumption.


Arterial hypertension is a disease with a complex pathogenesis. Despite considerable knowledge about this socially significant disease, the role of magnesium deficiency (MgD) as a risk factor is not fully understood. Magnesium is a natural calcium antagonist. It potentiates the production of local vasodilator mediators (prostacyclin and nitric oxide) and alters vascular responses to a variety of vasoactive substances . MgD stimulates the production of aldosterone and potentiates vascular inflammatory response, while expression/activity of various antioxidant enzymes  and the levels of important antioxidants  are decreased. Magnesium balances the effects of catecholamines in acute and chronic stress. MgD may be associated with the development of insulin resistance, hyperglycemia, and changes in lipid metabolism, which enhance atherosclerotic changes and arterial stiffness. Magnesium regulates collagen and elastin turnover in the vascular wall and matrix metalloproteinase activity. Magnesium helps to protect the elastic fibers from calcium deposition and maintains the elasticity of the vessels. Considering the numerous positive effects on a number of mechanisms related to arterial hypertension, consuming a healthy diet that provides the recommended amount of magnesium can be an appropriate strategy for helping control blood pressure. MgD leads to reduced 1,25(OH)2D and impaired parathyroid hormone (PTH) response. Absorption of Mg2+ and Ca2+ is inter-related. MgD impairs hypocalcemic-induced PTH release, which can be corrected after infusion of Mg2+. Mg2+ is also an important factor for the sensitivity of the target tissues to PTH. On the other hand, PTH has significant effects on Mg2+ homeostasis. For example, PTH release enhances Mg2+ reabsorption in the kidneys and absorption in the gut. PTH influences Mg2+ absorption, however, hypercalcemia antagonizes this effect [2+ are associated with high BP [2+ homeostasis disturbances.It is known that 1,25-dihydroxyvitamin D [1,25(OH)sorption . In addis effect . The fin high BP , which m2+ is one of the important physiological regulators of blood vessel tone. It improves vascular relaxation responses and attenuates agonist-induced vasoconstriction, thus mitigating the increased peripheral vascular resistance. The effects of Mg2+ as a regulator of vascular tone are most often the result of a competitive relationship with Ca2+. MgD increases the contractile response to various agonists and changes vascular responses to a number of vasoactive substances  breakdown, inhibits IP3-induced Ca2+ release from the sarcoplasmic reticulum, and competes with intracellular Ca2+ for cytoplasmic and reticular binding sites [2+ stimulates IP3 mediated mobilization of Ca2+ from the sarcoplasmic reticulum and reduces Ca2+ ATPase activity, decreasing Ca2+ efflux and reuptake by the sarcoplasmic reticulum. This leads to accumulation of cytosolic Ca2+, increased intracellular Ca2+ concentration, which is a crucial factor for vasoconstriction [2+ can also block Ca2+ release from the sarcoplasmic reticulum via the ryanodine receptor [2+ is to compete with Ca2+ for binding sites on regulatory molecule troponin C. Thus, Mg2+ regulates the activity of contractile proteins and their dynamics [2+ regulates activity of the G-protein-coupled receptors as AT1 (ATII), ETA (ET-1), V1a (vasopressin), and α1-adrenoceptors (norepinephrine and epinephrine) on VSMCs and intracellular Ca2+ signal transduction pathways as translocation of phospholipase C (PLC) and protein kinase C (PKC) activation [In the dissolved state, Mgon shell . Because+ levels . Ca2+ coagonists ,34,35. B closure . Elevatechannels . Intraceng sites . Low inttriction . Mg2+ careceptor . An impodynamics . Lastly,tivation .2+ on VSMCs, Mg2+ also modulates endothelial function, which in turn contributes to its vasodilatory actions. Normal endothelium plays a fundamental role in regulating vasomotor tone by synthesizing vasodilatory prostacyclin (PGI2) and nitric oxide (NO). Mg2+ has been shown to increase endothelial release of PGI2 in cultured human endothelial cells and in healthy human volunteers [Besides the direct effects of Mglunteers ,36. 2+ effects could be due to altered binding of agonists to their specific cell membrane receptors and/or the production of vasoactive peptides, such as ATII and ET-1, which are powerful vasoconstrictors [1 receptors, respectively, on VSMCs. Activation of these Gq–protein-coupled receptors initiates the PLC, IP3, diacylglycerol, Ca2+, and PKC signal transduction pathway. Evidence suggests that following receptor–ligand interaction intracellular Mg2+ is also altered and that it too functions as a second messenger to modulate signal transduction [2+ decrease ET-1 induced contraction, whereas decreased Mg2+ levels increase it [2+ compounds for the development of systemic inflammation and endothelial dysfunction in rats fed on a low Mg2+ diet for 74 days. Low Mg2+ diet reduces Mg2+ concentration in the plasma and red blood cells (RBCs), which is accompanied by a decreased concentration of endothelial NO synthase (eNOS), elevated levels of ET-1 in serum and impaired endothelial-dependent vasodilation. ET-1 produces multiple effects in the blood vessels: causes significant vasoconstriction, has proinflammatory effects, possesses mitogenic and proliferative properties, stimulates the formation of free radicals, and activates platelets. The analysis of the activity of the inorganic Mg2+ salts showed that supplementation with Mg-sulfate did not significantly reduce pathologically elevated levels of ET-1, but Mg-chloride completely restored the concentration of ET-1 to a normal value. Tested Mg-organic compounds Mg-oxybutyrate and Mg-L-aspartate reduce the concentration of ET-1 to a normal level, whereas treatment with Mg-N-acetyltaurate leads only to partial reduction of ET-1 in MgD groups [2+ is an essential cofactor of the enzyme δ-6-desaturase, which is the rate determining conversion of linoleic acid to gamma-linolenic, which in turn is converted to dihomo-γ-linoleic acid. The latter is a precursor of prostaglandin E1 (PGE1), which is both a vasodilator and inhibitor of platelet aggregation. MgD disrupts production of PGE1, which leads to vasoconstriction and increase in BP [Other Mgtrictors . ATII, Esduction . For exarease it . KharitoD groups . Mg2+ isse in BP .2+ was much lower than in normotensive persons [2 and vasoconstrictor prostaglandins [2+ has some direct effects on ALDO synthesis rather than indirect effects via the RAAS. ALDO secretion from the zona glomerulosa of the adrenal gland is Ca2+ dependent process. Mg2+ infusion in humans decreases the production of ALDO, by inhibiting the cellular Ca2+ influx. MgD facilitates cellular Ca2+ influx, which may stimulate the production and release of ALDO [2+ supplementation decreases ATII stimulated production and release of ALDO from the adrenal cortex of normotensive subjects [2+-recovering rats juxtaglomerular granulation index the width of the zona glomerulosa returned to normal [2+ entry, may promote ALDO production and release. Experimental studies have reported that MgD-induced HTN in rats is associated with increased vascular total Ca2+ content, and increased vasoconstrictor activity to endogenous agonists such as ATII and noradrenaline (NA) [2+ supplementation can reduce the pressor effect of ATII and stimulate the production of the vasodilator PGI2 [Few studies have investigated the effects of MgD on the hormonal systems which control BP. The RAAS plays an essential role in humoral and hemodynamic regulation . It was  persons . MgD incglandins . Mg2+ ha of ALDO . It was subjects . Rats feo normal . Thus, oine (NA) . Mg2+ sutor PGI2 .2+ exerts a major role in CA release from the adrenal gland and adrenergic nerve terminals in response to sympathetic stimulation. Because Mg2+ competes with Ca2+ for membrane channels, it can modify these types of Ca2+-mediated responses. The ability of Mg2+ to inhibit the release of CA from both the adrenal gland and peripheral adrenergic nerve terminals is well established in laboratory experiments. On the basis of these effects, Mg2+ can be used in patients where an excess of CA is prevalent, such as in phaeochromocytoma [2+ stimulates the secretion of ACh and there exists a direct relationship between Ca2+ concentration and the rate of CA release. Mg2+ antagonizes the stimulant effects of ACh on adrenal chromaffin cells; this effect can be overcome by the addition of Ca2+ [2+ is required for the catalytic action of adenylate cyclase (ADCY). For example, the decreased activity of the ADCY9 in the absence of Mg2+ results in increased secretion of ACh from preganglionic nerves, which in turn stimulates further release of CA from the adrenal glands [2+ together with ATP can greatly stimulate the release of CA from adrenal medullary granules. Neither ATP nor Mg2+ alone may have any effect on the release of CA. The effects of Ca2+, which cause the release of CA from the granules, are inhibited in the presence of ATP and Mg2+. The uptake of 14C-adrenaline (Adr) into the granules can also be stimulated by ATP and Mg2+ [Camocytoma . Acetylc of Ca2+ . Mg2+ isl glands . On the and Mg2+ . 2+ prevent the release of NA in some arteries by blocking N-type Ca2+ channels of nerve endings, which counteracts the rise in BP. Also rats fed with a MgD diet showed an increase in CA excretion [2+ and Mg2+ concentrations on responses to periarterial nervous sympathetic stimulation, NA, and tyramine have been investigated on the isolated rabbit central ear artery. An increase in Ca2+ concentrations potentiates responses to sympathetic stimulation until complete removal of Ca2+ inhibits these responses. The addition of the Mg2+ solution greatly reduced the responses to sympathetic stimulation, NA, and tyramine. These actions of Mg2+ on sympathetic transmission are important in determining the responsiveness of arterial smooth muscle to direct and indirectly acting sympathomimetic amines [2-agonist, on plasma Mg2+ levels, were studied in a placebo-controlled design in healthy subjects. Plasma Mg2+ levels fell significantly during the Adr infusion and also during the salbutamol infusion, though more slowly. It is propose that intracellular shifts of Mg2+ occur as a result of β-adrenergic stimulation [2+ levels in healthy males. This effect was abolished by simultaneous infusion of propranolol. NA had no such effect. These results suggest that the β-adrenergic system affect Mg2+ homeostasis [2+ was observed in rats infused with isoproterenol (ISO). Pretreatment with butoxamine or propranolol has prevented the ISO-induced increase in serum Mg2+ levels, whereas administration of atenolol has minimal effects. This evidence demonstrates the existence of a pool of Mg2+ that is mobilized into the circulation in response to selective β2-adrenergic stimulation [There are evidences that high concentrations of Mgxcretion . The effc amines . The effmulation . In anoteostasis . On the mulation .2+ concentrations play an important role in many of these processes.Normally conduit arteries adapt pressure and blood flow during cardiac systole to facilitate perfusion to tissues during diastole. This is determined in large part by the elasticity, distensibility, and compliance of the arterial system. Loss of elasticity and increased stiffness demand greater force to accommodate blood flow, leading to increased systolic BP and consequent increased cardiac work load. Multiple interacting factors at the systemic , vascular , cellular , and molecular  levels contribute to arterial stiffness in HTN. Dysregulation of endothelial cells, VSMCs, and adaptive immune responses are also implicated in HTN . Changes2+ is considerably lower in lymphocytes of the hypertensive patients, compared with healthy subjects, whereas serum Mg2+, erythrocyte Mg2+ and ionized platelet Mg2+ were not significantly different [2+ intake is associated with a higher probability of increased serum C-reactive protein (CRP) levels in children [2+ and elevated CRP levels in the adult population. Insufficient dietary intake of Mg2+ may be associated with an increased inflammatory response resulting in more frequent occurrence of cardiovascular accidents [2+ is also inversely related to the level of hs-CRP, interleukin 6 (IL-6), and fibrinogen [2+ deficit, in rats leads to an increase in the inflammatory mediators, such as histamine, IL-1, IL-6, TNF-α, and ET-1, which is associated with leukocytosis and generation of free radicals [A number of immunopathological mechanisms may be at the basis of HTN. There are evidence in animal models and humans that link HTN with changes in both humoral and cellular immunity, and in particular with the key role of low-grade vascular inflammation . One stuifferent . MgD leaifferent  in the vchildren . There iccidents . Intake brinogen . MgD sigbrinogen . This shbrinogen . For exaradicals    depend on the concentration of Mg2+ ions. Thus, low levels of Mg2+ could lead to decreased activity of HAS, and at the same time to an increased activity of HYAL. Tissue transglutaminase (TG2) is an enzyme of the transglutaminase superfamily that is ubiquitously expressed in the vasculature [2+-bound open conformation to catalyze the formation of isopeptide bonds [2+ may be limiting TG2 activity in the ECM [2+, and inhibited by Mg2+ [2+ can inhibit LOX, which is also associated with crosslinking of chains of elastin and/or collagen [Vascular remodeling is a permanent process of structural changes in the vessel wall in response to a number of hemodynamic stimulus . In HTN,glycans) . Hyaluroculature . TG2 is culature . TG2 is de bonds . Thus, C the ECM . TG2 is  by Mg2+ . A distucollagen ,64. Addicollagen .2+-deficient rats [2+ with MMP-2 . There was a similar correlation of Mg2+ with MMP-9 in patients with HTN and T2D . The results show that lower and higher serum Mg2+ levels correlate inversely with MMP-2 and MMP-9 levels in HTN [2+-deficient endothelial cells, MMP-2 and MMP-9 activity overrides the inhibitory effect of TIMP-2, which probably is induced as an attempt to counterbalance the effects of the proteases [2+ availability might directly increase MMP-9 expression via NF-κB [2+ significantly reduced the production of MMP-2 under basal and platelet-derived growth factor-stimulated conditions in a dose-dependent manner, while neither verapamil nor nifedipine showed any effect under the same conditions. These data suggest that the beneficial effect of Mg2+ supplementation on vascular disease processes may be due, at least in part, to the inhibitory effect of Mg2+ on the production of MMP-2 in VSMCs [2+ significantly reduced the production of MMP-2 in a dose-dependent manner [2+. MgD is associated with low elastase activity and an increased number of elastic fibers [Fundamental to many of the processes underlying ECM reorganization and fibrosis in HTN is activation of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs). ECM MMPs and TIMPs may contribute to the profibrotic phenotype in HTN. Activated MMPs degrade collagen, elastin, and other ECM proteins, resulting in a modified ECM, often associated with a proinflammatory microenvironment that triggers a shift of endothelial and VSMCs to a more secretory, migratory, and proliferative phenotype, which contributes to fibrosis, calcification, endothelial dysfunction, and increased intima–media thickness, further impacting on vascular remodeling and arterial stiffness . In endoent rats . In addient rats . These ds in HTN . It is nroteases . A nucleia NF-κB ,69. In cin VSMCs . Evidenct manner . MgD mayc fibers . Altura c fibers .2+ slows endothelial cell proliferation, stimulates the adhesion of monocytes, and affect the synthesis of vasoactive molecules, such as NO and PGI2. Endothelial function is significantly impaired in a model of familial hypomagnesemia in mice. Compared to controls, in the aortas of these animals were found reduced amounts of eNOS and increased expression of proinflammatory molecules, such as VCAM, PAI-1, as well as of the TRPM7 channel [2+ deficit is too important [2+ and results of Mg2+ supplementation have showed significantly improved endothelial function in patients with ischemic heart disease and diabetes. These results in humans have also been observed in different experimental models in which Mg2+ deficit affects vascular structure and function. Low levels of extracellular Mg2+ favor and increase endothelial permeability. More specifically, MgD enhance the transport of low-density lipoproteins (LDL) through the endothelial layer [2+ supplementation on plasma LDL levels, as well as on high-density lipoproteins (HDL) levels, which are increased [2+ contributes to the development of atherogenesis is through the effect on triglyceride levels which are increased in MgD. Accumulation of triglyceride-rich lipoproteins is accompanied by decreased concentration of HDL and increased plasma concentration of apolipoprotein B. Since the oxidation of lipoproteins play a key role in the development of atherosclerosis, it could be another mechanism by which Mg2+ influences. It is also possible proatherogenic lipoprotein changes found in MgD to be a consequence of the inflammatory response [2+ mediated effects on endothelial cells has IL-1α, which is regulated by NF-κB and may be inducer of the NF-κB. IL-1α increases significantly in the environment of low Mg2+ content. IL-1α also induces the production of various chemokines and adhesion molecules in vascular endothelial cells by activation of NF-κB, and thus favors aggregation, adhesion, and diapedesis of monocytes. In particular, low concentrations of Mg2+ stimulate the secretion of interleukin 8 (IL-8), and chemokines, which are overexpressed in human atherosclerotic lesions. IL-8 is essential for chemotaxis and adhesion of monocytes to endothelial cells, which is a fundamental event in the initiation of atherogenesis and also stimulates proliferation and migration of VSMCs. By induction of IL-1α, low serum Mg2+ may also stimulate overexpression of VCAM-1 on the surface of endothelial cells which assists in the migration of leukocytes. In addition, the secretion of granulocyte-macrophage colony-stimulating factor is significantly higher in endothelial cells with Mg2+ deficit [MgD may potentiate the development of endothelial dysfunction via activation of NF-κB, which includes the transcriptional program leading to development of the proinflammatory phenotype . Low ext channel . Endothe channel . The patmportant . This mimportant . Endotheal layer . Severalncreased . Anotherresponse . A centr deficit . All the2+ metabolism [The presence of MetS is also associated with altered Mgtabolism . Usuallytabolism . Furthertabolism ,80. A co2+ levels in people with MetS. The relationship between the intake of Mg2+ and MetS was investigated prospectively in 5115 young Americans (aged 18–30 years), initially without MetS and diabetes, which were enrolled in Coronary Artery Risk Development in Young Adults (CARDIA) study from 1985 to 1986. The total number of participants included in the analysis was 4637, and 74% were evaluated at the 15-year period in 2000–2001. During this interval 608 cases of MetS were diagnosed. The findings showed that young people with a high Mg2+ intake had a lower risk of developing MetS and that risk was dose-dependent [2+ levels, inflammation, and oxidative stress, as risk factors for the development of MetS. Mg2+ intake is inversely proportional to the components of MetS and fasting insulin levels, suggesting that higher Mg2+ intake may have a protective role against the risk of developing MetS [2+ deficit may be associated with the development of MetS. These findings support the hypothesis that MgD can play an important role in the pathophysiology of MetS, and the actuation of the inflammatory reaction caused by the shortage of Mg2+ could be the link between MgD and MetS [2+ levels with chronic inflammatory stress in obese people. Obesity affects over 35% of the adult population of the USA and is a main risk factor for chronic diseases, associated with a lower Mg2+ status, such as atherosclerosis and T2D. MgD is often found in people with MetS and T2D, which are connected with higher plasma concentrations of CRP [Currently, there is little data on serum Mgependent . Guerrering MetS . The resand MetS . Some sts of CRP . 2+ plays a very important role in the development of T2D [2+, compared with patients without metabolic risk factors. Furthermore, plasma triglycerides and waist circumference were independently associated with hypomagnesaemia [2+ is bipartite. Insulin regulates Mg2+ homeostasis, but on the other hand Mg2+ is a major factor determining insulin and glucose metabolism. Extracellular Mg2+ acts as Ca2+ antagonist and inhibits Ca2+ influx, required for insulin secretion. Thus a decreased concentration of extracellular free Mg2+ results in an increased Ca2+ influx and increased concentration of intracellular free Ca2+. The increased intracellular Ca2+ stimulates insulin secretion by beta-cells, as was demonstrated in experiments with an insulinoma cell line [2+ on insulin secretion was found in healthy human subjects. In subjects with 0.79 mmol/L plasma Mg2+, fasting plasma insulin was 23 μU/mL, while in those with plasma Mg2+ 0.87 or 1.00 mmol/L, fasting plasma insulin amounted to 11 μU/mL [Mgt of T2D . Corica nesaemia . T2D is nesaemia . The relell line . The eff11 μU/mL . 2+ metabolism for the occurrence of peripheral insulin resistance. MgD can lead to disturbances of the tyrosine kinase activity of the insulin receptor (IR), associated with the development of post receptor insulin resistance and reduced cellular glucose utilization, as a lower Mg2+ concentration, requires a greater amount of insulin for glucose metabolism [2+ metabolism induce insulin resistance is confirmed by data showing that lower dietary intake of Mg2+ is associated with insulin resistance. Rats fed on a low Mg2+ diet showed a significant increase of blood glucose and triglycerides. The insulin resistance, observed in the skeletal muscle of rats with MgD is partially associated with a defect of tyrosine kinase activity of the IR [2+ is a necessary cofactor in all ATP transfer reactions, intracellular Mg2+ concentration is critical in the phosphorylation of the IR and other kinases [2+ operates together with ATP as a kinase substrate. Additionally Mg2+ is bound to a regulatory site of the IR tyrosine kinase (IRTK). The apparent affinity of the IRTK for Mg2+-ATP increased as the concentration of free Mg2+ increased, and the apparent affinity of the IRTK for free Mg2+ increased as the concentration of Mg2+-ATP increased [2+ concentration and reduction of tyrosine-kinase activity at the IR level, which results in the impairment of insulin action and development of insulin resistance [2+ can also be a limiting factor in carbohydrate metabolism, since many of the enzymes in this process require Mg2+ as a cofactor during reactions that utilize the phosphorus bond [There are growing evidences that highlight the clinical significance of altered Mgtabolism . The efff the IR ,87,88. If the IR . Activatf the IR . When thf the IR ,92. Actif the IR . The PI3f the IR . Since M kinases . In all ncreased . There asistance . Studiessistance . Nadler sistance . Finallyrus bond .2+ is an independent risk factor for the development of T2D. Lopez-Ridaura et al., evaluating 37,309 participants free of cardiovascular disease and T2D, found a significant inverse association between Mg2+ intake and diabetes risk [2+-rich foods, particularly whole grains, is associated with a substantially lower risk of T2D [2+ supplementation in diabetic subjects have been found in some clinical studies. Rodriguez-Moran et al. reported that Mg2+ supplementation improves insulin sensitivity and secretion as well as metabolic control in patients with T2D [2+ supplementation on insulin sensitivity in overweight, nondiabetic subjects [Inadequate dietary intake of Mgtes risk . Van Damk of T2D . Benefitwith T2D . Mooren subjects .2+ in the arterial wall and is intimately linked with the HTN. On the other hand, HTN was considered a risk factor for atherosclerosis and associated calcification. Two types of extracellular vascular calcification are recognized, intimal and medial. Intimal calcification is exclusively associated with atherosclerosis. Medial calcification may contribute to increasing BP by decreasing the elasticity of the media. Decreased elasticity results in arterial stiffening which accelerates pulse wave velocity and widening the pulse pressure, leading ultimately to HTN. Intimal and, especially, medial vascular calcification are associated with arterial stiffening, the major cause of isolated systolic HTN in the elderly [2+ on vascular calcification was based on the observation that living cells are necessary for Mg2+ ions to exert its protective effect. These studies suggested a potentially active intracellular role for Mg2+ ions in attenuating the vascular calcification process [2+ intake and lower calcification of the coronary arteries [2+ levels prevented calcification of bovine VSMCs, and further progression of the already established calcification. Inhibition of the Wnt/β -catenin signaling pathway was identified as one of the possible intracellular mechanisms by which Mg2+ achieved its anti-calcifying effect [Vascular calcification is the extracellular deposition of Ca elderly . The fir process ,35,104. arteries . Further2+ content and intracellular Mg2+ tend to decrease with age. Aging is often associated with a Mg2+ deficiency due to reduced intake and/or absorption, increased renal wasting and/or reduced tubular reabsorption, as well as age-related illnesses and their treatment with certain drugs [2+ balance may prove to be an appropriate strategy against arterial aging due to its positive effects on low-grade inflammation and oxidative stress associated with aging process  . Mg2+ plstressor . MgD indstressor . MgD ress the BP . Additionesaemia .2+ ions also have a key role in the modulation of neurotransmission. Numerous studies have confirmed that the function of the native N-methyl-d-aspartate (NMDA) receptor is the result of equilibrium between extracellular and intracellular concentration of Mg2+. The blockade of the ion channel of the NMDA receptor is the most well-known and established way in which Mg2+ affects the functioning of the central nervous system (CNS) [2+ reduces neuronal hyperexcitability by inhibiting NMDA receptor activity and also is essential for the activity of metabotropic glutamate receptors (mGluRs) in the brain. The mGluRs play a key modulatory role in glutamatergic activity, secretion, and presynaptic release of glutamate, activity of the gamma-aminobutyric acid (GABA)-ergic system, and regulation of the neuroendocrine system. Mg2+ may additionally modulate anxiety via increasing GABA availability by decreasing presynaptic glutamate release. GABA is a primary inhibitory transmitter in the CNS that counterbalances the excitatory action of glutamate [2+ and its loss in the urine, because in stressful situations secreted elevated amounts of Adr and NA help to remove Mg2+ from the cells. Intracellular RBCs Mg2+ depletion is found in patients with HTN. MgD affects the balance of monoamines, such as CA and serotonin in the brain. CA released into the blood is rapidly inactivated by the enzyme catechol-O-methyl transferase (COMT). The latter is activated by Mg2+ and is inhibited by Ca2+. MgD leads to decreased activity of COMT, which in turn increases the concentration of circulating CA [2+ levels. NA levels were significantly higher in MGL than in MGH mice. These data together with the higher urinary NA excretion observed in the MGL line might account for the higher sensitivity and/or reactivity of MGL animals to stress [2+ loss. In the long run, type A individuals would develop a state of MgD, which may promote a greater sensitivity to stress, and ultimately to the development of CVD [2+ depletion, but acute stress that increase serum concentrations of CA may lower serum Mg2+ concentration, which does not always imply depleted tissue Mg2+ stores [Mgem (CNS) . Mg2+ relutamate . The staating CA . Brain No stress . Moreoveo stress . An analt of CVD , includi+ stores . 2+ in attenuating psychological response to stress merits further investigation since stress is a ubiquitous feature of modern life. The modulation of HPAA by Mg2+, which has been shown to reduce central (ACTH), peripheral (cortisol) endocrine responses [2+ supplementation in patients with HTN.The potential effect of Mgesponses , and red2+ status in the human body may help prevent or treat HTN. Although most epidemiological and experimental studies support a role of MgD in the pathophysiology of HTN, data from clinical studies have been less convincing [2+ and BP remained inconclusive, but not in others [2+ level in hypertensive patients was inversely proportional to the systolic BP. The study examined a cohort of 15248 participants aged 45–64 years [2+ resulted in a significant reduction in both systolic and diastolic BP (2.00 mmHg and 1.78 mmHg respectively) [2+ supplementation, for example 243 mg/day can significantly lower BP in patients with uncomplicated HTN, treated six months or longer with antihypertensive drugs [2+ concentration [2+ in adults suggest that oral Mg2+ supplements may be recommended for the prevention of arterial HTN or as adjuvant antihypertensive therapy [2+ status and high BP, some hypertensive patients constantly demonstrate hypomagnesemia. Among them are patients with obesity, insulin resistance, hypertriglyceridemia, severe forms of HTN, hyperaldosteronism (volume-dependent HTN), pregnancy induced HTN, and patients of African-American origin [2+ in clinical HTN, Mg2+ supplementation is advised in those hypertensive patients who are receiving diuretics, who have resistant or secondary HTN or who have frank MgD [2+ for adult women are set at 255–265 mg and 310–320 mg/day, respectively. The EAR and RDA of Mg2+ for adult men are set at 330–350 mg and 410–420 mg/day, respectively. These dietary reference intakes are based on data from 16 men and 18 women who have consumed self-selected diets and have had a decreased Mg2+ intake during the balance periods, which could have affected balance values [2+ ranges from 80 mg/day for children 1–3 years of age to 130 mg/day for children 4–8 years of age. For older males, the RDA for Mg2+ ranges from as low as 240 mg/day  and increases to 420 mg/day for males 31–70 years of age and older. For females, the RDA ranges from 240 mg/day (9–13 years of age) to 360 mg/day for females 14–18 years of age. The RDA for females 31–70 years of age and older is 320 mg/day. Many nutritional experts feel the ideal intake for Mg2+ should be based on the body weight  [2+ supplementation may be more effective, but this treatment has the disadvantage that it requires regular hospital visits. The treatment regimen of intravenous Mg2+ supplementation normally consists of 8–12 g of Mg-sulfate in the first 24 h followed by 4–6 g/day for 3 or 4 days. When serum Mg2+ levels are extremely low or are accompanied by hypokalemia, Mg2+ supplementation may not be sufficient to restore normal Mg2+ levels. In that case, patients are often cosupplemented with K+ or receive amiloride to prevent K+ secretion [2+ concentrations >0.75 mmol/L, or high as 0.85 mmol/L, could be Mg2+-deficient. Thus, to assess Mg2+ status of an individual with a serum Mg2+ concentration between 0.75 and 0.85 mmol/L is requires additional measures of status. A urinary excretion of <80 mg (3.29 mmol)/day and/or dietary intake history showing a Mg2+ intake of <250 mg/day would support the presence of MgD [2+ salts, such as Mg2+ citrate, gluconate, orotate, or aspartate, because of their high bioavailability [HTN is a complex, heterogeneous disorder whose etiology, pathogenesis, and treatment still raises some unresolved questions. Maintenance of optimal Mgnvincing . In somen others . Ultimat64 years . In anotctively) . An analve drugs . Moreoventration . The evi therapy . It shoun origin . In viewrank MgD . In the e values ,123. Theecretion . Recent e of MgD . In the lability .2+. Excessive intake of supplemental Mg2+ can result in adverse effects, especially in impaired renal function. Serum concentrations >8 mmol/L cause drowsiness, vasodilation, slowing of atrioventricular conduction, and hypotension [Hypermagnesemia is a rare condition and is seen most often in patients with renal impairment who take medicines containing Mgotension ,127,128.2+ is subnormal, with shortfalls of between 65 and 225 mg of Mg2+/day, depending upon geographic region. Several epidemiologic studies in North America and Europe have shown that children and adults, some which are pregnant women, consuming Western-type diets are low in Mg2+ content  [2+ intake and BP [2+ intake for the reduction of BP and total CVD risk. These findings support the importance of increasing the consumption of Mg2+-rich foods, including fruits, vegetables, nuts, and whole grains in the treatment and prevention of high BP [2+-rich diet should be encouraged in hypertensive subjects as well as in predisposed communities because of the advantages of such a diet in the prevention of HTN [2+, K+, Ca2+, dietary fiber, and protein and smaller amounts of total and saturated fat and cholesterol than the typical diet [2+, dietary fiber, antioxidant capacity, and polyphenolic compounds [2+ and K+) and their reduced fat content. In observational studies, significant inverse associations of BP with intake of Mg2+, K+, Ca2+, and fiber have also been reported [In the Western World, dietary intake of Mglations) . Epidemie and BP . Overall high BP . A Mg2+-n of HTN . The Diecal diet . The Medompounds . In triareported .2+ intake. Typically, water with increased “hardness” has a higher concentration of Mg2+ salts. Since this varies depending on the area from which water comes, Mg2+ intake from water is usually not estimated to a sufficient extent. This omission may lead to impaired assessment and underestimation of total intake of Mg2+ in certain regions [2+ and is spreading globally, makes this well-researched potential of drinking-water Mg2+ worth serious consideration, especially in areas where insufficient dietary intake of Mg2+ is prevalent. It would be wise and forward-thinking for public health officials to consider how high-Mg2+ drinking water might be made available to communities, i.e., water with Mg2+ levels of at least 10 mg/L and ideally 25–100 mg/L [Water is a variable source of Mg regions . The mod100 mg/L . 2+ in each individual patient with HTN. Special attention should be given to the risk groups in which serum Mg2+ levels should be monitored periodically. Considering the numerous positive effects of Mg2+ on a number of mechanisms related to HTN, consuming a healthy diet that provides the recommended amount of Mg2+ can be an appropriate strategy for helping control BP.The enhancing effect of MgD on BP should be considered in the context of total intake and loss of Mg


Management of such strictures post-cystectomy can be quite challenging and this highly skilled team from the Cleveland Clinic led by Dr. Kaouk illustrate how it can be approached using a minimally invasive approach in a systematic and methodical manner allowing its reproducibility and adoption by others across the world. The 2nd Prize is awarded to the video by Velilla et al. (see video) highlights how minimally invasive robotic surgery can be offered to patients suffering from multi-organ site endometriosis through the coordination and team work of multi-disciplinary surgical teams. The authors nicely highlight the key steps in conducting such complex procedures offering critical details to conducting such procedures at other international centers of excellence. It is of note that embarking on such multi-organ and specialty procedures requires methodical review of pre-operative imaging and defining the affected sites of disease which will help determine the location/number of port placements, the enumerated steps of the procedure, and which surgical teams should participate and in what specific order they should proceed. This truthfully reminds me of a symphonic orchestra working in a harmonious and coordinated manner. Last but certainly not least, the 3rd prize for best video of the year is awarded to the video by Sonawane et al. (see video). There are many qualities related to this work including the meticulous review by the authors of their completed cases ultimately providing insight to improving patient outcomes through their only 5 cases (0.6%) of vascular injuries among their large cohort (N=858) of completed laparoscopic donor nephrectomies between 2011 and 2016. This video very elegantly depicts what can be done to avoid such injuries and if they in fact infrequently occur, how can they be managed to minimize their meaningful sequelae. There are important lessons depicted within this video that broadly apply to many facets of other laparoscopic and open surgical procedures within and outside of urology ie meticulous review of pre-operative imaging and managing such vascular complications through effective and clear communication while maintaining a calm demeanor.This year has been another exceptional year for the International Brazilian Journal of Urology with a significant increase of quality video submissions. I am truthfully amazed by the innovative and beautifully depicted videos sent to us from across the world. It is through this commitment to continually refining our surgical approaches and techniques that we will set new benchmarks of excellence in our surgical specialty. In making this selection for best videos of the year, many criteria are taken into account including originality, quality of video depiction and narration, and novelty in re-defining surgical standards. In this regard, I am pleased to announce the top 3 videos of the year. The 1st Prize is awarded to the video by Garisto et al. (In my concluding remarks, I would like to thank and congratulate our outgoing editor-in-chief Dr Sidney Glina on his exceptional leadership and vision for our journal over his very successful term. Similarly, I would like to congratulate Dr. Luciano A. Favorito in being elected as the new editor-in-chief for our journal and very much look forward to working as part of your executive editorial team.Warmest regards and best wishes to all our readers and contributors for the holidays and the New Year. Very much looking forward to receiving your quality submissions in 2020.


Video review for quality and education purposes has been a valued tool for decades. However, the use of this process dropped significantly after the development of the Health Insurance Portability and Accountability Act in the 1990s. Video review was recently reestablished at our institution. By working with our institutional legal counsel and risk management team, we have been able to create a video review process that complies with legal requirements. Literature on this subject has not described the process of obtaining video recordings. We aimed to review the process of obtaining high quality recordings in a secure manner. We hope that in the future, the data collected through our multidisciplinary review process will be helpful in improving quality of care for injured patients and providing coaching and feedback to learners, as well as improving our trauma education curriculum. Video review for quality and performance improvement has been used in multiple fields since the 1960s.Video review for resuscitation was common in the 1980s and 1990s. A survey of trauma centers in densely populated regions of the United States (U.S.) published in 1999 revealed 20% of trauma centers were using video review, the majority of which were designated Level I trauma centers. In the study, 34% of Level I trauma centers surveyed had a video process in place for trauma resuscitation. Of the hospitals discontinuing their video review programs and those that had never used videotaping, the primary issues were medicolegal concerns and inadequate support from personnel and staff. Interestingly, surveyed hospitals actively using video review reported no medicolegal issues.4The enactment into law of the Health Insurance Portability and Accountability Act (HIPAA) in 1996 discouraged many institutions from continuing this practice due to concerns regarding patient privacy and legal implications. A survey of 125 trauma centers in the U.S. in the early 2000s revealed that only 15% used a video review process, while 40% had previously had a video review process that was no longer used. The majority of these institutions reported HIPAA compliance and scarce resources as reasons for discontinuing their process.5At our institution, the video review process in place in the 1990s was discontinued when a state law on voyeurism was enacted in 2001, making it illegal to video record anyone in an undressed state without prior written informed consent.Recognizing its potential value for education and quality improvement, our institutional legal counsel and risk management developed solutions in 2015 to comply with state and federal regulations. Instrumental in this process was the language present in the Conditions of Admission (COA) form patients or their designees sign during the registration process. This document includes a section on video recording for the purpose of education and quality improvement. The consent form includes the following: “I consent to the recording, photography, closed circuit monitoring or filming for the purposes of treatment  or quality of care and teaching.” The consent is valid for one year after signing.When a patient is critically ill and cannot sign a COA, the patient may physically or verbally sign at a later time. A family member can also sign for the patient. It is rare that a COA is not obtained. This occurs in cases such as death occurring prior to obtaining a signature, the patient is unidentified, or no family is available. This process allows us to comply with state and national regulations and limits the risk assumed by providers, as they are considered protected by our hospital quality improvement process. Along with this new COA, the risk management team assisted in developing a secure process for recording and data keeping. Integral to this process is the choice of technology and software.Avigilon™ in-ceiling Micro Dome cameras  were installed in three of our four trauma resuscitation bays where all of our trauma team activation patients arrive. Cameras are positioned overhead to capture care and procedures. Recordings are manually activated by a set of pushbutton switches in the center of the room. Each resuscitation bed has an individual activation button and light indicator (red or green) to indicate whether recording is live.We initially encountered challenges developing a process to ensure video recording was activated on patient arrival. This task was assigned to our trauma technicians. In addition, we added this task to our huddle checklist performed by our physician providers prior to patient arrival. The recorded cases are stored on an isolated computer using Avigilon software. The password-protected computer is located in a locked closet with access limited to the emergency department (ED) director. In addition, this computer has no connection to the internet or campus network. Total cost for the technology and installation was approximately $9,000.A weekly report of patients evaluated in the trauma resuscitation area is downloaded from the electronic health record (EHR). The report contains arrival time stamp, medical record number and chief complaint. The report is imported into a secured database created for case tracking and video review data collection. Cases with trauma-related chief complaints are selected for assessment of COA status in the EHR and ED disposition. In addition, cases identified through other venues are also identified as candidates for review . Patients with a COA on file within the prior 12 months will have the video recording computer checked for the presence of a recorded video. Recordings of non-trauma related cases or those without a COA on file are immediately destroyed prior to any review. Video recordings meeting requirements for consent are then downloaded onto an encrypted flash drive for subsequent review.Recordings available on the computer are reviewed by either the ED director or the director of clinical operations to assess for quality. Those recordings lacking large portions of care or any sound or that have video quality issues are discarded. In addition, patients are excluded if they were discharged from the ED. Deaths occurring within the resuscitation bay are included if an active COA was on file from a previous encounter. All videos are discarded after 30 days.A multidisciplinary video review committee was created for quality review. This team includes designated faculty members from emergency medicine, trauma surgery and anesthesia. In addition, the trauma program manager, trauma performance improvement coordinator, ED nursing leadership, and the lead ED technician are also present.A secure database was developed to keep records of the review process and assist with communication to the team regarding outcomes of reviews. In the database, patients are identified by a video number and medical record number. Review areas include general impression of the case and issues identified with members of the care team . A section for overall learning points is provided. Finally, there is an area to list any issues identified and document a plan of action. The videos are then flagged if valuable for our monthly, multidisciplinary trauma conference. A case can also be flagged if issues arise requiring a formal quality review as part of the requirements set out by the American College of Surgeons Committee on Trauma (ACS-COT). For the purposes of education, mechanism of injury and any procedures recorded are documented.Videos are used for training, education and coaching for physician providers and nursing. Recordings are integrated into a monthly, multidisciplinary emergency medicine/trauma conference. Videos considered to be of value demonstrate effective utilization of ATLS principles, as well as show the impact of deviation from these protocols. Videos demonstrating procedural technique, leadership skills and team dynamics are used for physician coaching. The video process allows the trauma medical director to address inefficiencies or gross deviations in policy and guideline performance issues with providers in a one-on-one setting. This is used to satisfy requirements in performance improvement set forth by ACS-COT. In addition, videos are also flagged for a nursing educational archive. Nurse management uses recordings for orientation training, procedure technique improvement, and direct feedback regarding team care of an injured patient.Video recording for the purposes of quality improvement and education in medicine has been used for decades. The use of this process for trauma care in particular was widespread prior to the development of multiple federal and state privacy laws across the U.S. We recently began using this tool again at our institution. By working with our institution’s legal counsel, we were able to reestablish trauma video recording within the guidelines of the established privacy laws. Ongoing data collection from this process will allow our group to assess its value for the purposes of process improvement and education.


Increasing children's time outdoors, and reducing near work, can delay the onset of myopia – which reduces the risk of high myopia and its complications.Children who develop myopia at an early age have a greater risk of eventually developing high myopia (≤ −5 dioptres [D] of correction). High myopia increases the risk of retinal detachment, macular degeneration, open-angle glaucoma and cataract. One of the most cost effective ways to reduce this is to prevent or delay the onset of myopia.The rapid rise in myopia prevalence in recent decades is likely due to environmental factors, such as living spaces ,Children who perform more near work are more likely to have myopia, and the odds of this increases with additional near work activities each week.Interestingly, studies have also found that more time outdoors delays myopia onset.Evidence suggests that a multi-pronged approach with reduced near work , living spaces with more natural light as well as promoting time outdoors could be beneficial in delaying or preventing myopia onset. These strategies also have other health benefits, such as reduced risk of obesity and improved physical activity and mental health, so all children will benefit if these are implemented.


Ten healthy volunteers were studied during a double desaturation hypoxic challenge. Video-PPGs were generated from the acquired video image stream and processed to generate heart rate. HRvid was compared to the pulse rate posted by a reference pulse oximeter device (HRp). Agreement between video-based heart rate and that provided by the pulse oximeter was as follows: Bias = − 0.21 bpm, RMSD = 2.15 bpm, least squares fit gradient = 1.00 , with a 98.78% reporting uptime. The difference between the HRvid and HRp exceeded 5 and 10 bpm, for 3.59 and 0.35% of the reporting time respectively, and at no point did these differences exceed 25 bpm. Excellent agreement was found between the HRvid and HRp in a study covering the whole range of skin pigmentation types , using standard room lighting and with moderate subject motion. Although promising, further work should include a larger cohort with multiple subjects per Fitzpatrick class combined with a more rigorous motion and lighting protocol.The robust monitoring of heart rate from the video-photoplethysmogram (video-PPG) during challenging conditions requires new analysis techniques. The work reported here extends current research in this area by applying a motion tolerant algorithm to extract high quality video-PPGs from a cohort of subjects undergoing marked heart rate changes during a hypoxic challenge, and exhibiting a full range of skin pigmentation types. High uptimes in reported video-based heart rate (HR The determination of physiological parameters from video image streams has attracted significant attention in recent years, with a variety of signal processing and hardware approaches employed [There is a major effort across patient monitoring to develop wireless solutions: whether to allow for untethering of the patient in the home environment or the de-cluttering of cables in-hospital. This can be achieved either through a wireless transmission technology where a probe —is highly susceptible to three main confounders: motion artefact, lighting levels (both low levels and dynamic variations) and skin pigmentation. A variety of powerful signal processing methods has been proposed to determine heart rate from the video-PPG. These include frequency-based methods such as spectral peak tracking , and FouThe effect of skin pigmentation on the video-PPG has been investigated by a number of researchers. The variation in skin tone may be stratified according to the Fitzpatrick scale , which vThe work reported here extends current research in this area by studying a cohort of healthy volunteers exhibiting distinct heart rate changes due to being subjected to a rigorous, protocolized hypoxic challenge and incorporating a full range of skin pigmentation types according to the Fitzpatrick scale . The algorithm used to determine heart rate was constructed in order to extract valid video-PPG signal across the full range of skin types in relatively low room lighting condition. In addition, a degree of motion tolerance was desired to address the natural movement of the subjects during the challenge. In this way we strove to achieve high uptimes  while retaining accuracy in the measurements.The data was collected opportunistically during a non-related study to measure the effect of various interventions on the reported values of another monitoring device. Part of this parallel study protocol involved two desaturation events conducted in close succession, and data from these events were collected for the video research work. The study also involved the acquisition of reference pulse oximetry pulse rate data . Approval was given for the use of video monitoring and no other alteration to the existing protocol was made.2 using a mixture of nitrogen and oxygen and induce desaturation. Each subject underwent two discrete episodes of hypoxia. The sequence of targeted oxygen saturation levels is highlighted in Fig. Eleven healthy volunteers participated in the study. Subjects provided an institutional review board (IRB) approved informed consent covering the essential information stated in the protocol, as required elements according to 21 CFR 50.25 (27) for a non-significant risk medical device investigation. The subjects were fitted with a face mask in order to adjust the FiOThe video image stream was captured using a scientific camera (Basler acA1920-155uc with Nikon AF-S NIKKOR 35 mm 1:1.8G lens) at a frame rate of 70 fps. Video footage was acquired during each of the two desaturation events. The camera was placed on a tripod at approximately 2 m from the subject’s head and the data streamed to a laptop via a USB cable. Subject illumination was via fluorescent room lights on the ceiling, approximately 2 m above the subject’s head. Light intensity at head level was 250 lx measured using a DT-1309 light meter .The production of a robust heart rate requires two main steps: a biosignal extraction algorithm to produce the video-PPG from the video image stream and a vital sign processing algorithm which processes the video-PPG in order to determine the heart rate. These are discussed detail as follows:The video-PPG signal was generated from a region of interest (ROI) on the image selected using a flood-field algorithm. This comprised identifying a seed point on the forehead, setting lower and higher tolerances for skin color around the seed point representing the maximum allowable relative changes between adjacent pixels, and performing a flood fill operation for each frame which recursively aggregated all adjacent pixels within the pre-set tolerance, starting from the seed point. The mean pixel modulations across the field were then used to construct the video-PPG. Figure vid) was computed automatically from the resulting frequency spectra by an algorithm which determined the physiologically relevant local peaks in the spectrum: this was defined as the dominant peak in the spectrum in a range between 0.5 and 4 Hz corresponding to heart rates between 30 and 240 beats per minute.Once generated, the video-PPG requires further processing to extract the physiological parameter of interest: here the heart rate. This comprised the processing of the green channel using a fast Fourier transform (FFT) applied over a sliding temporal window of length 18 s. The video heart rate (HRp). The video derived heart rate was then aligned in time with the reference rate to allow a comparative analysis of the two signals as described in the next section.A Nellcor™ sensor  was attached to the subject’s finger and provided a reference pulse rate  and represents a combination of the systematic and random components of the error.R and associated p values were computed. In this work p < 0.05 was considered statistically significant.Least-squares linear regression was performed to obtain the line of best fit between the video and reference parameters from which the gradient, intercept, Pearson correlation coefficient A Bland–Altman analysis of the data was also performed using the method of  which coOutlier statistics E5, E10 and E25 were calculated: these are defined as the percentage of the time that the absolute difference between the video heart rate and pulse oximeter reference exceeded 5, 10 and 25 bpm respectively and provide an indication of the algorithm’s susceptibility to reporting markedly erroneous results.An uptime was determined, defined as the percentage of time that each parameter could be calculated when there was a valid reference value posted by the pulse oximeter.The described signal and image processing were performed using in-house C++ code. Statistical analysis was carried out in Matlab, version R2016b.vid time series for all 20 desaturations episodes with the reference HRp signal also plotted for comparison. The variation in heart rate caused by the desaturation events is obvious in the plots. Each subject varied their heart rate over a range (maximum–minimum) induced by the hypoxic challenges. This range of heart rates varied across volunteers from 14.1 to 38.5 bpm, with a mean range of 24.1 bpm. The data is represented more compactly in Fig. vid against HRp for all the data. The figure also includes the associated Bland–Altman analysis plot with the limits of agreement shown. The least squares regression line is plotted on the figure and has the equation: HRvid = 1.00 HRp − 0.39. The Pearson correlation is R = 0.99 (p < 0.0001). The overall bias and RMSD were found to be − 0.21 and 2.15 bpm respectively. The E5, E10 and E25 values were 3.59, 0.35 and 0%. The latter indicating that no computed HRvid deviated by more than 25 bpm from the reference pulse oximeter pulse rate. An uptime of 98.78% was achieved across the whole data set. Figure Figure Excellent agreement was found between the computed video heart rates and the reference oximeter pulse rate with an overall RMSD of 2.15 bpm (bias: − 0.21) achieved at a 98.78% uptime. This is within the typical operating ranges of heart rate devices used in practice and well within the accuracy specified in ANSI/AAMI EC13: 2002 where an accuracy of ± 10% or ± 5 bpm, whichever the greater, is specified . RMSDs ranged from 1.74 to 2.89 bpm when split according to skin tone scale, with no obvious pattern discernable Similarly the bias, E5, E10, E25, and uptimes all showed no discernable pattern when split according to skin type. The overall E5 value of 3.59% compares favourably with the work of  who founGiven the small data set (N = 20: 10 subjects each with 2 desaturations) and its use in developing the algorithm, over-training is a possibility, and results must be viewed in this context. Further, this limited data set resulted in only 1 or 2 subjects per Fitzpatrick scale and the results again should be viewed in this context. To this end, the algorithm presented here was compared to four alternative versions containing slight code variations. These were: (1) PPG processed using only the green channel; (2) PPG processed using the red and green channels; (3) A weighted averaging of the FFT spectrum between frames; (4) as (3) but with a longer FFT window of 30 s instead of 18 s. These resulted in reasonably similar performances, but exhibited localised failure modes in short sections of signal. These distinct failure modes for the alternative algorithms are shown in Fig. We have described the motion in this study as ‘moderate’. There is, however, no strict definition of motion in this area at present. In fact, the issue of motion has not been rigorously studied to date and many reported studies simply manually remove data where there is motion with no indication of its nature nor criteria given for its removal. In the study presented here we included all signals from all subjects from a real environment in our analysis and thus targeted a 100% uptime; which is a main goal of medical monitoring. Rather than exclude signal, we have attempted to cope with the motion that was present in the study algorithmically.Even for traditional pulse oximetry, a mature area of clinical monitoring, there are no universally accepted motion characteristics. Instead, companies develop their own internal protocols and analysis tools for specific studies. Recently, our group proposed a novel motion protocol for video monitoring including yaw, pitch and roll maneuvers of the head , althougThe question, whether video-based heart rate monitoring could replace other modalities for monitoring this vital sign in the clinical environment, is still open. There may, however, be specific clinical use cases where the technology may be adopted more readily in its current state. For example, spot checks by the clinician using, for example, a pulse oximeter may allow intermittent calibration of a camera-based heart rate monitoring system to allow continuous monitoring to take place with reasonable accuracy between checks. The home environment is another area of interest as more monitoring is taking place in order to reduce costs and improve out-of-hospital care. In addition, the monitoring of heart rate using video methods may be combined with other video monitoring technologies relevant to the clinical environment, including the monitoring of oxygen saturation , 24, resThe results provide a strong indication of the potential to determine heart rate from video image streams of subjects exhibiting a range of skin pigmentations with moderate motion. Further work is required to fully test this technology in a more rigorous fashion, where a range of motion, skin pigmentations and ambient lighting levels is considered within a comprehensive protocol.


Moral psychology has relied nearly exclusively on text stimuli in the development and testing of theories. However, text stimuli lack the rich variety of morally-relevant social and contextual cues available in everyday interactions. A consequence of this pervasive ecological invalidity may be that moral psychological theories are mischaracterized by an overreliance on cue-impoverished moral stimuli. We address this limitation by developing a cue-rich Moral and Affective Film Set (MAAFS). We crowd-sourced videos of moral behaviours, using previously validated text stimuli and definitions of moral foundations as a guide for content. Crowd-sourced clips were rated by 322 American and 253 Australian participants on a range of moral and affective dimensions, including wrongness, moral foundation relevance, punishment, arousal, discrete emotion-relevance, clarity, previous exposure, and how weird/uncommon the moral acts were. The final stimulus set contained sixty nine moral videos. Ratings confirmed that the videos are reliably rated as morally wrong and feature a variety of moral concerns. The validation process revealed features that make the MAAFS useful for future research: (1) the MAAFS includes a range of videos that depict everyday transgressions, (2) certain videos evoke negative emotions at an intensity comparable to mood induction films, (3) the videos are largely novel: participants had never seen more than 90% of the videos. We anticipate the MAAFS will be a particularly valuable tool for researchers in moral psychology who seek to study morality in scenarios that approximate real-life. However, the MAAFS may be valuable for other fields of psychology, for example, affective scientists may use these videos as a mood induction procedure. The complete stimulus set, links to videos, and normative statistics can be accessed at osf.io/8w3en. To date, moral psychology has relied disproportionately on text-based stimuli in the development of theories and in the testing of empirical research questions. Reviews by Boccia, Dacquino  and ChapEveryday interactions are rich in social and contextual cues that guide interaction  and enabImportantly, many of these verbal and non-verbal cues are directly relevant to moral judgement. For example, facial expression and voice tone communicate emotions , 14 whicGrowing evidence indicates that the medium used to present a stimulus or complete an experimental task can affect outcomes. For example, a message is more persuasive when presented with a rich medium (video), compared to when that same message is presented using text or audio . LikewisImportantly, presentation medium also affects morally relevant constructs. For example, participants attribute fewer humanness qualities to a target that is presented using text than voice , 27. CooPresentation medium may not only affect moral judgement quantitatively , but also qualitatively . Text-stimuli are often more abstract than image or video stimuli because written language requires the reader to draw on his or her own mental representation of the stimuli to fill in the blanks. Video (or images) instead fill in the blanks for an observer by depicting more concrete stimulus features . AbstracWe provide the means for researchers to address the possibility that moral psychological processes are mischaracterised by the overreliance on text stimuli by developing a moral film set, the MAAFS. We selected video as a presentation medium as it confers numerous advantages for use. First, the multi-modal nature of videos means that they closely approximate the real world, but do not pose the ethical and practical problems associated with placing participants in real, morally compromising situations . Second,Our key goal was to develop a video stimulus set of ecologically valid, contextually rich stimuli encompassing a wide range of moral content. We thus used the broadest and one of the most prevalent characterizations of morality in psychological research, moral foundations theory, as a framework for the development of our stimuli . MFT catvideo collection phase, Amazon Mechanical Turk (MTurk) participants searched YouTube for potential clips using either vignettes that represented the moral foundations [video validation phase, on a range of moral dimensions. These validated videos were assessed against a second set of inclusion criteria (detailed below). The retained and rated videos (N = 69) formed the final video set. An overview of this process is presented in We developed the MAAFS using pre-existing video clips hosted on the video streaming website, YouTube. In the ndations , 8 or deEthics for both the video collection and video validation studies were approved by the University of Melbourne, Human-Ethics Sub-Committee (HESC number: 1545466).Mage = 32.8, SDage = 10.1). The sample was highly educated on average: 85% of participants had some level of college education. No other demographics were collected.175 participants from MTurk participated in the video collection phase  must be one minute or less in length, (2) must be hosted on YouTube, (3) must not contain obscene or offensive content , (4) must not include text as a central feature, (5) must be a moral transgression and not a praiseworthy action, (6) must be of actual scenes, events, people and real objects (not animations). Participants were then required to submit a URL link to a YouTube video for each vignette or foundation definition. Participants were instructed that they could submit clips that were conceptually similar to the moral vignettes if an exact video match could not be found. Finally, participants were told that they could describe a video (e.g. a scene from a specified movie) if they were able to recall an appropriate video from memory but could not source a URL.We received 742 video submissions in total: 344 videos were identified based on vignette search prompts; 398 videos, on the basis of definition prompts. The first and third authors reviewed each crowd-sourced video and made judgements regarding: (1) how well it represented the original vignette (vignette-based searches only), (2) how well it represented any moral event related to the target moral foundation, and (3) fulfilment of the video criteria. Videos that were judged as inappropriate or inadequate on the basis of these criteria were removed from the next stage of video validation.Nvignette = 40, Ndefinitions = 34) fulfilled our stringent inclusion criteria. Participants had more success in identifying videos primarily related to the care (N = 17) and fairness (N = 15), than to loyalty (N = 8), sanctity (N = 10), and liberty (N = 3). Consequently, we manually searched for video clips for these under-represented domains. We again used the vignettes as a guide and followed the criteria given to MTurk searchers. Nineteen additional videos were identified to give a total of 93 clips. Videos were assigned an initial ‘associated foundation’ as per the moral foundation classification of the previously validated vignette search prompts  or the foundation definition.74 videos . The sample was composed of 14.2% self-identified political conservatives, 26.6% liberals, 13.5% moderates; 45% of participants chose to not to respond to this question. American participants received a small monetary reward, while Australian participants were undergraduate psychology students that participated for course credit.Videos were validated using a sample of Australian undergraduates and American MTurk participants. We restricted MTurk workers to those with approval rates ≥ 90%, and ≥ 100 previously approved HITs. After excluding 7 participants for failing attention checks, our final sample comprised 575 participants, including 253 Australian undergraduates and 322 American MTurk workers. The sample was 44% male and had an average age of 29.57 (M = 41.7). This number of ratings per stimulus is consistent with the validation procedure in the comparable moral text stimulus set, the moral foundation vignettes [Sample size was determined based on a target of obtaining at least 30 ratings for each video on each dimension, although the average number of ratings was considerably higher  46). This scale has been used for the validation of several affective film sets , 46 and . This scParticipants then rated how frequently they witness or hear about the kind of moral act displayed by the video in their daily life and how weird the act is  .Participants next reported whether they have previously seen the video clip and briefly described the actions depicted in each video to ensure both that the clip was free from technical problems and that the moral action was clearly depicted. Participants further verified the clarity of the clip and the absence of technical problems by rating each of these variables on a Likert scale.Three videos were reported as causing technical difficulties and so were removed from the final video set. Videos were excluded from the final stimulus set if more than 20% of participants selected the option “the clip is not morally wrong” when asked to select a description of why the clip was morally wrong. Twenty-one videos were removed on this criterion, leaving 69 videos conveying content deemed morally wrong. Summary descriptions of the final video set are presented in Summary descriptive statistics for the MAAFS are presented in Although all foundations were represented by multiple videos, the individualising foundations (care and fairness) were best represented: 24 clips were classified as care violations, 18 as fairness, 12 as authority, 5 as sanctity, 6 as loyalty, and 4 as liberty. One video was primarily classified as ‘moral–other’.N = 1252), harm was by far the most common type of moral behaviour experienced (50.6%), followed by fairness (13.9%), while the binding foundations were relatively uncommon experiences . The MAAFS has a similar distribution: videos are primarily represented by the individualising foundations (34.8% harm violations and 26.1% fairness) and fewer videos represent the binding foundations . Despite differences in methodology, the similarity in distributions of moral foundations suggests that the MAAFS samples types of moral acts at a similar frequency to which they occur outside the laboratory.This distribution of moral content is similar to the distribution found by experience sampling of everyday moral behaviour . In a launiqueness score for each video. To calculate this score, we took the percentage frequency that a given video was categorised as belonging to the target foundation and subtracted the percentage frequency that the video was categorised as belonging to any other moral foundation. A uniqueness score of 100 would indicate that all participants categorised the video as belonging to the target foundation, while a uniqueness score of -100 indicates that no participants categorised the video as belonging to the target foundation. Uniqueness scores for each video are available in M = 22.2; SD = 36.7). The overall distribution of uniqueness scores demonstrates that videos vary in the extent to which they uniquely represent moral foundations. Care, fairness and loyalty each had high maximum values, implying that at least one video in each foundation had very high, positive uniqueness scores. Importantly, each of care, fairness, loyalty, authority and liberty have at least two videos with positive uniqueness scores, indicating the presence of videos in these foundations that predominately (if not exclusively) represent each foundation. Sanctity videos tend to overlap with the ‘moral other’ category and, thus, have low uniqueness scores. We suggest that this overlap demonstrates poor folk understanding of what defines sanctity, or a mismatch between folk and theoretical definitions. Although these videos are judged as morally wrong, participants don’t clearly categorize these videos into the sanctity foundation. We further explore the overlap between the moral foundations in supporting information  and minimum value (2.74) for wrongness ratings. Clarity ratings were similarly distributed, with a high mean rating  and minimum value (5.08), indicating that moral transgressions are clearly conveyed by the MAAFS videos.First, the MAAFS contains stimuli that clearly convey moral Arousal was near-normally distributed across the video set, with most videos clustering at the mid-point of the scale , although some videos evoked either very high or low arousal. This is consistent with our expectation that the moral content presented in video format would be effective at inducing (at least some) arousal, but also permits sampling across the arousal spectrum. Arousal was strongly and positively correlated with both wrongness and punishment .The final set contains videos that can induce several morally relevant emotions. The distributions of discrete emotions are visualised in Other-condemning emotions were successfully induced across the video set. Across the MAAFS, there were high mean values for disdain, anger and moral disgust. There are individual video clips in the database that induced (on average) “a lot” of disdain, anger, and disgust . Certain videos were also effective at inducing shame, fear, physical disgust, sadness, surprise and anxiety , suggesting that most videos evoked some interest from participants. This may imply that the cue-rich quality of videos as a communication medium creates an engaging way of conveying moral content. There was a moderate, positive correlation between the extent to which the video evoked interest and wrongness ratings .r = -0.54), punishment (r = -0.47), and arousal (r = -0.56).Videos were normed on funniness as there is some evidence that violations that elicit laughter may be judged differently (including less wrong ); the raBmoral = 0.863, pmoral < 0.01, Bphysical = -0.75, pphysical = 0.478; F = 63.150), with an equivalent pattern of results when regressing punishment onto each type of disgust  = 12.92, VIF = 2.17, tolerance = .47).The MAAFS could delineate between moral disgust and physical disgust. Recent research has shown that disgust is not unitary: moral and physical disgust are distinct (but correlated) variables . These fIt is possible that participants may have had some prior exposure to some MAAFS videos as the stimulus set contains movie/television video clips. Thus, we assessed the naivety of participants to these videos and whether previous exposure influences judgments. First, more than 90% of videos were rated as a < 2.0 (on average) for previous exposure, which equates to “never seen before”. Second, we assessed if previous exposure affected how participants . PreviouSome researchers have raised concerns about the lack of ecological validity of typical moral stimuli, such as sacrificial dilemmas , 53, 54.r(67) = .329, p = .006). Less weird videos tended to be classified as loyalty violations (r(67) = -.245, p = .043). To further investigate the effect of weirdness and commonness on foundation classification, we regressed the frequency that each video was classified as sanctity onto both weirdness and commonness. The pattern of effects support the correlational analyses: weirdness significantly predicted sanctity frequency, while commonness was a non-significant predictor  = 5.44, VIF = 3.15, tolerance = 0.32). These analyses suggest that the sanctity violations videos are not unusually uncommon, but tend to be judged as weirder than violations in other foundations.As mentioned previously, Gray and Keeney (50) argue that existing sanctity stimuli suffer from a confound with weirdness. We assessed whether weirdness and commonness of the action varied as a function of moral foundation using bivariate correlation. We correlated the frequency that each video was categorised into each moral foundation with weirdness and commonness: commonness was not correlated with the (frequency of) categorisation into any moral foundation, but videos that were deemed weird were more frequently categorised as sanctity  and arousal. One possibility is that the liberal bias of Mechanical Turk and undergraduate university students may affect attributes of the MAAFS.First, mixed-effects models with random intercepts for participant and video were fit to assess the effect of each of economic, social, and overall political orientation on ratings of arousal and, separately, wrongness judgements. There were no significant effects of political orientation for either model, suggesting that on average, economic, social, and political orientation did not alter ratings of arousal or wrongness . Of courTo examine the role of political orientation on moral foundation categorisation, a series of logistic regressions were fitted predicting categorisation of each foundation  from social, economic, and overall political orientation . Only thTaken together, the results of these analyses indicate that the moral and affective ratings of the MAAFS are not biased by political characteristics of the sample. However, we encourage additional testing with samples with different demographics to further validate the stimulus set and ensure that normative ratings are generalizable across other dimensions of demographic diversity.The MAAFS has a wide range of possible applications for psychological research. These videos can be used as the direct object of moral judgement, as a complement to text-vignettes. The cue-rich and dynamic nature of these clips allows researchers to explore a variety of interpersonal moral constructs such as, judgements of the victim’s/perpetrator’s moral character, attributions of blame or causality, intentionality, and empathy, in a non-text medium.Researchers can use the normative ratings and video descriptions in Moral psychology researchers can use the MAAFS to study the contribution of specific information channels to moral judgement. Researchers can systematically vary cues by presenting participants with the MAAFS videos, audio-only versions of the MAAFS , videos with no audio, and text-vignette transcriptions.The MAAFS can be used to induce moral emotions and study their effects. Videos vary, for example, in the extent to which they elicit moral or physical disgust, and thus may be used to disentangle effects of distinct disgust types in the moral domain. Likewise, the stimulus set can be used to induce the moral emotions of anger, contempt, and guilt.Affective scientists can use these videos to induce  emotions and study their effects. The MAAFS has been normed on the same discrete emotions used to validate affective video sets and analyses reveal that the MAAFS performs equally or better at the induction of negative emotion  when compared with existing affective stimulus sets , 45, 46 While the MAAFS has many possible applications and provides multiple benefits to the moral psychology research community, there are a number of limitations that should be noted.One possible limitation of video stimuli is that they may be more time consuming to administer than text stimuli. However, this difference is offset (in part) by the increased efficiency of videos to convey rich information, compared to text. Text conveys information using only verbal cues, while videos convey information with both verbal and non-verbal cues. The question of whether text or film delivery of given semantic content is preferable will depend on the specific research questions under consideration.Researchers should also be mindful of the content of the clips and the appropriateness for their specific research goals. In certain circumstances, responses to a given stimulus could vary systematically according to certain demographic or psychological factors . For some research questions, this could be a serious confound, whereas for others it could be a desirable stimulus feature. As with any research endeavour, stimulus selection should be tailored to research goals. The MAAFS provides a variety of dimensions on the basis of which stimuli can be selected and tailored to specific research ends.Finally, as noted previously, the uniqueness scores were relatively low for many video clips. This suggests that at least some of the videos may not be suitable for studying certain claims of moral foundations theory (which may require stimuli that are uniquely representative of single foundations). The MAAFS was not intended to be a moral foundations stimulus set, so although this is a limitation, it does not preclude the MAAFS being used for a variety of purposes within moral psychology. We encourage future research using these stimuli to measure moral foundation categorisation in a range of ways and contribute this norming information to the Open Science Framework (osf.io/8w3en).Moral psychology has near-exclusively relied on text stimuli in the development and testing of theory. However, text stimuli lack the rich variety of morally-relevant social and contextual cues available in everyday interactions. The reliance on text-based stimuli may have systematically biased empirical research and psychological theories. Consequently, current moral psychology perspectives may not accurately account for moral phenomena in non-text or real-world contexts. We provide researchers with the means to move beyond the limits of text-stimuli by developing a cue-rich moral and affective film set (MAAFS). The MAAFS includes moral transgressions that are diverse in content, intensity, and elicited emotions. We anticipate that the MAAFS will provide researchers with new insights into current theories and tools to develop a more complete understanding of moral psychology.S1 TableContains the list of moral vignettes used as search prompts in the development of the MAAFs, including those moral vignettes that were changed and excluded.(DOCX)Click here for additional data file.S2 TableContains the moral foundation definitions used as search prompts.(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 TableContains all descriptive statistics for the MAAFs across all domains, for each video, including those videos that were excluded from the final video set and results that were specific to each cultural group.(XLSX)Click here for additional data file.S5 TableContains details of an exploratory factor analysis of discrete emotions that was used to calculate summary scores for positive and negative affect.(DOCX)Click here for additional data file.S1 FigContains a systematic exploration of the extent to which the Moral Foundations overlap in the MAAFS.(DOCX)Click here for additional data file.S2 FigWe present a number of analyses that explore the performance of the MAAFS as a mood induction procedure, compared to pre-existing affective stimulus sets.(DOCX)Click here for additional data file.S3 Fig(DOCX)Click here for additional data file.S1 FileWe address copyright issues for video stimuli in research.(DOCX)Click here for additional data file.