Audiovisual educational material has been used effectively as a knowledge translation strategy in patient education. Given the need to impact maternal mortality rates, 12 video clips related to maternal and neonatal health information were designed based on the results of a previous systematic review (SR). The content was formulated based on clinical practice guideline recommendations and validated following a formal consensus methodology. This study evaluated the effectiveness of knowledge transfer from the 12 video clips in terms of attention, emotional response, and recall by using neuroscience tools. In a randomized cross-over trial, 155 subjects  received random sequences of 13 video clips, including a control video clip. Participants’ attention levels were evaluated through eye tracking, their emotional reactions were monitored by electrodermal activity and pupillary diameter, and their recall was tested via a questionnaire. An analysis was performed to evaluate differences in the groups and between the video clips and the control clip using variance analysis models that considered period, sequence, and carry-over effects. Results revealed that fixation length was greater in women than in men, while the greatest emotional effects occurred in men. All three groups had good recall results, without any significant differences between them. Although the sequencing did influence attentional processes, no carry-over effect was demonstrated. However, a differential effect was noted among video clips in all three outcomes, that is, when adjusted for group, level of education, and having had children. The control clip generated less attention, emotional reaction, and recall than the experimental video clips. The video clips about maternal and neonatal health were shown to be effective in the transference and comprehension of information. Therefore, cognitive neuroscience techniques are useful in evaluating knowledge translation strategies through audiovisual formats. Improving maternal health and reducing maternal mortality are priorities in public health. At the global level, the importance of intensifying the efforts of national action plans in this regard is reinforced through the prioritization of the health of women and children . In ColoIn order to identify the causes of high maternal mortality, a systematic analysis was developed by the WHO , which rThe existing gap between knowledge generated through research and its application has been recognized as one of the most critical public health challenges we face today, and knowledge transfer (KT) can address this gap –7. ConseThe use of reminders and video clips ensures that scientific evidence will be accessible to decision-makers and health providers . A systeCognition is the ability to recognize and process information by using knowledge to modify preferences; in problem-solving it is related to reasoning, learning and drawing conclusions , 11. MemAlthough social scientists commonly use research tools such as interviews or self-declared questionnaires, these are insufficient to gather all the necessary data , becauseA method widely used in neuromarketing is eye tracking, a technique that allows the detection and recording of eye movements. During the execution of a visual task, the relationship between eye movements and cognitive processes such as language and image processing, memory processes, social cognition, and decision making can be examined ,21. Eye Thus, the facilitation of the dissemination of health knowledge can also be based on the results obtained from cognitive neuroscience strategies applied to marketing, or neuromarketing, as it is known in the fields of economics and advertising . These sThe protocol for this trial and supporting CONSORT checklist are available as supporting information; see th, 2015 (No. CE201503). The trial was registered before participants were recruited on the international trial register . The authors confirm that all ongoing and related trials for this intervention are registered.The study protocol was approved by the Research Ethics Committee of the Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.) on July 7A randomized, open crossover trial was conducted, where each participant included in the study received randomly-generated sequences of 13 video-clips (one of them as a control). The randomization method was based on the algorithm designed by the eye tracker (Tobii TX300), which uses the Latin squares design to create the sequences, constructing (x) number of presentation sequences, according to (n) number of video clips selected to be randomized, and defining video clip 13 (the control) as the basis for randomization. Through this method, the allocation concealment was also guaranteed, since neither the patient nor the researcher knew the presentation sequence of the videos. Due to the nature of the interventions and the outcome measurement method, blinding of subjects or researchers was not possible. The sample was obtained through intentional, non-probabilistic sampling; participants included were pregnant women, non-pregnant women, and men over 18 years of age. Subjects were excluded if they displayed health problems related to pregnancy or some clinically significant visual or auditory disorder. The CONSORT flow diagram of subject recruitment, allocation and analysis is shown in Each subject was exposed to 13 video clips containing information regarding maternal and neonatal health. These consisted of:Intervention videos: 12 video clips about prenatal control (video clips 1 to 4), labor and delivery care (video clips 5 to 8), and postpartum and newborn care (video clips 9 to 12) were made. Each video aimed at providing important information during each of these stages. These video clips were made with mixed 2D and 3D elements. Every video was about 45 seconds long, and their format and content were prepared based on the best available evidence, obtained from a SR (Phase I) ) and clihttps://www.youtube.com/watch?v=VghQlqtX71U. A section of the video was used for the purposes of this study.Control video: video clip in 2D, with information about prenatal control presented in a conventional format . It was obtained from the link: After each video there was an eight second rest period (wash out period), during which a neutral sequence was presented with the intention of calibrating the response of the individual in a neutral state and thus, be able to control the carry-over effect. The participation of the subjects was voluntary, and the measurements were carried out by trained personnel, after obtaining written informed consent. The content of the videos was not explained either before or during the test. Participants were recruited between May and June 2017 through phone calls, online calls and social networks. The sessions were held in the Laboratory of Cognitive Neuroscience and Communication of the National University of Colombia, from June 23 to July 21, 2017, with an approximate duration of 30 minutes per participant.Attention and emotional reaction outcomes were measured through techniques used in neuromarketing: eye movements and pupillary diameter through the eye-tracking method, and electrodermal activity measurement employing a galvanometer.Attention: the eye-tracking method was used to evaluate the subject´s attention to the visual stimulus of the video clips, using the Tobii Tx300 Eye Tracker equipment. Eye movements were recorded during each video presentation. The following variables were measured, which registered how and when was the subject’s focus on the AOIs: 1) time to first fixation (TFF) in seconds on an AOI , and 2)The screen-time of each AOI and the duration of subject fixation on each AOI was recorded in seconds. A proportion between the subject fixation time and the screen-time of each AOI was then calculated to make the results comparable despite the differences in AOI screen-time. Subsequently, to obtain a final measurement per subject, an average of the data was calculated, obtaining the proportion of fixation time over AOI screen-time for each video. To obtain the time to the first fixation on an AOI, the time elapsed from the beginning of each AOI to the exact time of fixation on the area was measured. Then for each subject, the average time to first fixation per video clip was calculated.Emotional reaction: the monitoring of the autonomous activity to evaluate the subjects´ emotional state or reaction was carried out by recording electrodermal activity. This phenomenon is related with the sweat glands´ response to a stimulus, which alters the skin´s electrical properties . The eleIn addition to the recording of the electrodermal activity, the emotional reaction was also evaluated by measuring the pupillary diameter (in mm) per millisecond with the visual tracking equipment (the eye tracker), since the reaction of the pupil is a psychophysiological indicator of cognitive and emotional processing . AlthougAdditionally, pupil dilation is associated with the activity of the locus coeruleus  which isRecall evaluation: The assessment of the recall component was carried out by having participants complete a knowledge test in the form of a questionnaire after each video clip had been watched. The questionnaires, each with two or four questions, were prepared by the researchers based on the information presented in each video clip and on the AOIs. As the number of questions per questionnaire differed between video clips, once the total of correct answers per questionnaire had been established, the proportion of correct answers was calculated with respect to the total number of questions .In total, 6 subjects were excluded from the analysis as a result of incomplete recording of the electrodermal activity or ocular tracking due to equipment failure. In total there were 19 sets of missing data , corresponding to missing measurements for some videos owing to technical failures in the measurement of the electrodermal activity and eye tracking. These data were imputed using the last observation carried forward method ,41.For the calculation of the sample size, the statistical power analysis program G* Power 3  was usedA descriptive analysis of the data was carried out, with the qualitative variables presented in proportions and the quantitative variables by measures of central tendency and dispersion depending on their distribution (Shapiro-Wilks test). An overall analysis was made for the levels of attention, emotional response and recall among groups , by level of education and having had children, using the Kruskal-Wallis test or Wilcoxon sum rank test, depending on the number of levels of each factor. As a result of the multiple comparisons between attention, emotional reaction and recall, the level of significance was adjusted to a p<0.0025, using the Bonferroni correction method for multiple comparisons ,45.Because this is a crossover trial, one of the main drawbacks is the carry-over effect: this effect can be controlled or prevented by introducing a wash-out period between interventions, which must be long enough to eliminate the effects of a process . In thisThe final sample consisted of 161 subjects, with an average age of 27 years, and with a similar distribution among the three groups. The proportion of subjects by level of education was similar among groups, with a higher number of participants at the high school and undergraduate levels (77%) .Attention: for all the videos, the proportion was higher in the group of pregnant women compared to the other two groups. Significant differences were observed among the groups for video clip 11 (p<0.0025) . Fig 2 sParticipants without education had the lowest fixation levels, and a similar trend was identified in non-pregnant women and men with elementary education. The differences between levels of education were observed mainly in video clips 2, 5, and 7; however, no significant differences were demonstrated. It was also observed that subjects without children had a longer fixation time in the AOIs, especially in the first six video clips, video clip 12 and the control video.With respect to the time to first fixation, the data again showed better results in the group of pregnant women, that is, a shorter time to first fixation. The longest times were reported by men in six of the thirteen video clips; however, for the control video the longest time to the first fixation was that of non-pregnant women . RegardiIn the comparison between subjects with and without children, it was observed that for subjects without children, there was a shorter time to first fixation in the AOIs in each of the three groups, except for the first three video clips in the group of pregnant women. Video clip 9 showed the smallest difference between the two groups of having and not having children. The differences these two groups were observed mainly in video clips 11, 12 and 13, but were not statistically significant.Emotional reaction: the analysis of electrodermal activity was carried out using the results of the positive amplitudes by AIOs of each video clip for each subject , which amounted to 14% of all the amplitude data, of which 31.6% corresponded to non-pregnant women, 37.3% to the group of men and 31% to the group of pregnant women. The electrodermal response amplitude used in the ANOVA model with pkcross corresponds to the mean of the transformed variable  of the positive amplitudes for each video. On the other hand, when making comparisons between groups and videos the variable that was not subjected to transformation  was used, and therefore the results are presented as the median of the positive amplitudes for each video, together with the corresponding dispersion measure. The amplitude was greater in men, and significant differences were observed when comparing the results of this group with those of the group of pregnant women, in whom the amplitude of all video clips was less than 4 μS, suggesting a greater emotional impact in the men. Video clips 1, 6 and 11 produced a greater emotional response within the total sample, whereas video clip 5 and the control video were those that generated lower amplitudes; however, the differences between video clips are not significant .The group of pregnant women showed the lowest amplitudes, but there were no obvious differences between levels of education. On the contrary, among men and non-pregnant women a greater emotional impact was observed in those with highest levels of education (undergraduate and postgraduate), but significant differences were only noted in video clip 10 (p = 0.001). In the comparisons between having and not having children, it was observed that in subjects who had no children there was a greater emotional impact among all three groups, although this finding was more evident in men and non-pregnant women; the differences between having and not having children for non-pregnant women were significant only in video clip 8 (p = 0.002).For the majority of the videos, the pupillary diameter was highest in men, and significant differences were found for all the videos when comparing the groups . The groThe result of the electrodermal activity in the analysis of variance did not show variability between subjects or intra-subjects; the effect of sequence was not proven, nor were the period and carry-over effects, so the emotional impact measured via electrodermal activity is not dependent on the differences between videos or on the effect of a video previously seen , model 1Recall: there were no statistically significant differences among the groups, with all the subjects in the sample answering correctly to most of the questions asked. While there was a good recall of the information in all the videos, the best-recalled video clips were those from 1 to 3 and 11, and the lowest recall was for the control video. In the comparison between each video-clip and the control, significant differences were identified in all the comparisons (p <0.001). Regarding the level of education, the results showed that the higher the level of education (undergraduate and graduate), the greater the information recall. The video clips 5, 8 and the control video produced the lowest scores among those with the lowest levels of education (none and elementary) and the control video produced the lowest scores in the rest of the levels.In the variance analysis for the recall outcome, there was no variability between subjects, implying that there was no sequence effect, but there was intra-subject variability from a period effect. However, a carry-over effect was not evident, so therefore memory differs between video clips, but this response does not depend on the effect of the previous video , model 1This study is one of the first to implement a neuromarketing strategy to evaluate an audiovisual KT tool in maternal and neonatal health. The study was done as a crossover trial, which also included within its development the implementation of research in epidemiology, cognitive neuroscience, and other disciplines. This study identifies methods to reduce the gap between formulating evidence and applying it in order to benefit patients ,10,47. IResearch in neuroscience aimed at the perceptions and reactions to commercial ads has heretofore focused mainly on evaluating the effectiveness of advertising campaigns in the field of neuromarketing ,50,51 orSince a carry-over effect was not observed in any outcome the wash-out period implemented in this study was effective in eliminating the influence of a video clip on the one following it. It was also observed that the sequence effect, the order in which the videos were presented, did exert influence on the attentional processes, both in the time of fixation in the areas of interest and in the time to the first visual fixation. This is relevant because the study by Geiger et al., which evaluated participants’ attention to televisual clips, showed that subjects develop expectations about the next visual stimulus in a sequence based on the information of previously presented stimuli . HoweverBetween groups, there was a longer fixation time for the pregnant women, followed by the non-pregnant women this would seem to indicate that women tend to have greater attentional focus than men. Despite these differences, Video Clips 8, 9, and 11 had the longest fixation time across all three groups. The time to the first visual fixation followed a similar pattern and was quickest in the group of pregnant women as well. This would indicate that those who scan the screen more widely take a longer time to identify the AOIs. In this sense, the video clips were effective in attracting the attention of pregnant women in the AOIs, which represent the segments of special relevance. Similar findings were reported by Cárdenas et al., who found that visual attention was more stable in women than in men . Other sSubjects with lower educational levels had shorter visual fixation times. In some studies, it has been observed that individuals with a higher level of education support their visual tracking strategies with executive functions that favor concentrating one’s attention on the key elements of a scene ,59,60. SThe least-recalled video clip in all three groups was the control video clip, and the differences were significant when compared with each video clip. The control video clip differed from the others in several design aspects. It did not contain any 3D animation, the narration was presented in a foreign accent, and the video clip had background music, abundant text, and used static images. This finding reaffirms the results of the SR of the first phase and leads to the conclusion that the strategies implemented in the design of the experimental videos facilitated the attention and recall processes. Although no differences were found between the groups, as with the attention process the level of education indicated that the level of recall in the individuals with a lower educational level is lower; this could be related to the lower attention as observed in the times of fixation or to a lower short-term memory capacity in this group .With regard to the familiarity effect, it was observed that the participants who did not have children were more focused on the video clips, displaying more time in fixation, a faster time of arrival to AOIs, and a greater percentage of recall. This is likely related to a greater influence of top-down attention, since these subjects had to reject other stimuli in the visual periphery that was equally interesting, that is, their interest guides their observations and facilitates the acquisition of knowledge ,64.The emotional reactions, measured both by recording electrodermal activity and by pupillometry, show that pregnant women have a lower emotional reaction to stimuli. In men, the stimuli had more of an emotional effect. Also, whereas pregnant women maintained a stable emotional state throughout their viewing of the video clips, the men and the non-pregnant women had more variable reactions. However, during the video clips that presented information on warning signs during pregnancy and postpartum care (Clips 4 and 12), pregnant women did react with higher pupillary diameter and amplitudes. Differences in terms of emotional reactivity between men and women have been previously reported; in this regard, women have been described as having a greater excitement in most emotions compared to men, which shows that when watching videos that induce an emotional response, men frequently show more intense emotional experiences, while women experience a greater emotional expressiveness. .In general, the video clips that performed best in all the outcomes were Clips 8 and 9. This was possibly due to the fact that in Clip 8 (pain management) the narration of the information was supported by images that covered much of the screen, thus reducing the elements of distraction, and Clip 9 displayed highly emotional content, since it emphasized skin-to-skin contact with the newborn child and breastfeeding, with few elements of distraction.Taking this study into account, it is clear that the design of educational audiovisual material for the health sector should use strategies that make the information easier to understand, such as minimizing distractions, presenting information of short duration, and using simple language with scenarios with which viewers can identify .Some limitations of this study are: 1) the participants at the lowest level of education represented only 13% of the sample, limiting the generalizability of results for this subgroup; 2) there may have been possible conditioning effects for some participants because they knew in advance that they would be tested on the video-clip information (Hawthorne effect); and 3) the recall evaluation immediately followed the experimental presentation, and no follow-up evaluations were made.The strengths of the research outcomes are that the participants had good retention and understanding of the information that was presented. Moreover, since the design and statistical analysis methods employed for this study are not commonly used in the evaluation of psychophysiological variables, even though frequently in this type of research, the measurements are often repeated on the same subject ,67,68. TThe tools of cognitive neuroscience (neuromarketing) could become useful in the evaluation of attention, emotional response and memory in scenarios of educational strategies in health and public health interventions, which have the purpose of improving outcomes through the social acceptance of knowledge. Video clips of knowledge about maternal and neonatal health demonstrated greater effectiveness in the acquisition of knowledge, in terms of attention, emotional reaction and recall, compared with the control video. Audiovisual educational material must be clear, have short messages, and should not have distracting or redundant elements in order to reach a bigger proportion of the population.S1 Checklist(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.


Improving the reach of behavioral health services to young adult veterans is a policy priority.The objective of our study was to explore differences in video game playing by behavioral health need for young adult veterans to identify potential conditions for which video games could be used as a modality for behavioral health services.We replicated analyses from two cross-sectional, community-based surveys of young adult veterans in the United States and examined the differences in time spent playing video games by whether participants screened positive for behavioral health issues and received the required behavioral health services.Pooling data across studies, participants with a positive mental health screen for depression or posttraumatic stress disorder (PTSD) spent 4.74 more hours per week (95% CI 2.54-6.94) playing video games. Among participants with a positive screen for a substance use disorder, those who had received substance use services since discharge spent 0.75 more days per week (95% CI 0.28-1.21) playing video games than participants who had not received any substance use services since discharge.We identified the strongest evidence that participants with a positive PTSD or depression screen and participants with a positive screen for a substance use disorder who also received substance use services since their discharge from active duty spent more time playing video games. Future development and evaluation of video games as modalities for enhancing and increasing access to behavioral health services should be explored for this population. Behavioral health issues such as posttraumatic stress disorder (PTSD), depressive disorders, and substance use disorders (SUDs) are common diagnoses among veterans from recent conflicts in Iraq and Afghanistan ,2. HowevYoung adult veterans report multiple barriers to seeking and receiving behavioral health services in traditional settings and formats. These include inconvenience of appointments, concerns about high costs, perceived stigma from peers, beliefs that they can handle symptoms on their own, and living in rural settings that are far from care settings ,4,10-14.Video games have the potential to improve the reach of behavioral health services , includiIn this exploratory study, we replicated analyses from two cross-sectional, community-based surveys to explore the plausibility of video games as a modality for behavioral health services for young adult US veterans. The lack of data on veteran video game playing precluded us from making clear a priori hypotheses regarding the prevalence of video game playing in the sample. As video game-based interventions appeal more to those who play video games generally , the lacData presented in this manuscript are from two surveys conducted as part of a larger randomized controlled trial (RCT) of a Web-based normative feedback intervention for heavy drinking young adult veterans ,26. We cWe recruited nontreatment seeking young adult  veteran participants in both samples through advertisements on Facebook that did not mention video games or behavioral health. We have previously reported comprehensive details of the recruitment strategy and methods for validating veteran participants for Study 1  and StudStudy 1 involved a survey on the behavioral health symptoms of a large general sample of young adult veterans recruited outside of VHA settings. We targeted a series of Facebook ads to users between the ages of 18 and 40 years who expressed an interest in  specific veteran or military Facebook pages as well as media  related to military . Interested Facebook users who clicked on ads were directed to a Web-based informational statement and consent form. Eligible participants who consented to participate were first verified to be actual veterans using data check procedures we have described in detail elsewhere , before Study 2 involved a screening and baseline survey for an RCT of a brief, Web-based, personalized normative drinking intervention, where participants saw feedback about their drinking (intervention) or video game playing behavior (control) compared with their peers. As with Study 1, participants clicked on targeted Facebook ads, although we did not include ads targeting any media regarding video games . The eligibility criteria were the same across studies, except that participants in Study 2 needed to score at least a 3  or 4  on the 10-item Alcohol Use Disorders Identification Test (AUDIT) . These AWe recruited 1023 young adult veterans overall, of whom 552 (53.9%) reported playing video games at least 1 hour per week. To match the eligibility criteria of Study 2, we restricted the subsample who reported playing video games at least 1 hour per week to the 350 veterans who also had scores of at least 3  or 4  on AUDIT.We recruited 784 young adult veterans overall. Because we were interested in veterans who reported any video game use for analyses in the current study, we restricted our sample to 582 veterans  who reported playing video games at least 1 hour per week.For both studies, we collected information on demographics, behavioral health symptoms, behavioral health services use, and video game behaviors. In this manuscript, we report analyses on similar constructs assessed in both Study 1 and Study 2, although we operationalized several constructs using different measures  and 2.Participants in both studies filled out the same measures regarding age, gender, ethnicity or race, education, marital status, number of children, annual household income, and branch of military service.Participants completed brief screening measures for behavioral health problems.In Study 1, we assessed PTSD symptoms with the 4-item Primary Care PTSD scale (PC-PTSD). A score of 3 or higher  on PC-PTSD indicated a probable diagnosis of PTSD . In StudIn Study 1, we assessed depression symptoms with the 2-item Patient Health Questionnaire (PHQ-2). Participants rated two symptoms  from 0 “not at all” to 3 “nearly every day” for the past 2 weeks. A score of 2 on the PHQ-2 indicated screening for a depression diagnosis . In StudIn both studies, we assessed alcohol use disorder (AUD) symptoms in the past year using AUDIT . A scoreWe asked participants if they used any cannabis or marijuana in the past 6 months (yes or no), and if so, how many days in the past month did they use. The Study 1 survey referred to the drug as cannabis and the Study 2 survey referred to it as marijuana.In both studies, participants indicated whether they had attended any appointments  for mental health concerns or substance use concerns since discharge from active duty in the past month or year.In both studies, participants indicated the typical number of hours they played video games per day, hours they played video games per week, and days they played video games per week in the past 30 days using slightly different methods. In Study 1, participants indicated how many hours on each day of the week they typically played video games, while in Study 2, they responded to 3 single items about the hours per day, hours per week, and days per week they typically played video games. In both studies, participants were asked to consider computer-based games, console video games, arcade video games, mobile phone or tablet games, or Web-based JavaScript games.t test to examine whether participants who screened positive for a behavioral health issues played video games to a different degree than those who did not screen positive. Lastly, among participants who screened positive for behavioral health issues, we used Welch’s t test to examine whether those who received services played video games to a different degree than those who did not report using any services. We examined the results from the analyses on behavioral health and video game behaviors in two ways [P<.05 in same direction in both studies). Second, we calculated the fixed-effect meta-analytic estimate for the mean difference in effects by pooling differences from both studies [We first calculated descriptive statistics for, and differences in, demographics between Study 1 and Study 2 samples. Then, we used Welch’s two ways ,38. Firs studies .21=6.8, P=.009 (N=931). Study 1 had significantly more Hispanic participants  than Study 2 , χ21=19.1, P<.001 (N=931). Study 2 had more White participants  than Study 1 , χ21=8.7, P=.003 (N=932). A substantial majority of participants in both Study 1  and Study 2  had not earned a college degree, although more participants in Study 1  were currently in college than in Study 2 , χ21=13.2, P<.001 (N=932). In both studies, the modal annual household income was US $25,000 to US $49,999; about half of the participants in each study were married, with an average of one child per veteran. Among those with children, the average number of children living at home was 2. The majority of participants in both studies served previously in the army, with about a quarter previously serving in the marines.We included 350 participants from Study 1 and 582 participants from Study 2 see . The ave21=16.3, P<.001 (N=932). However, compared with participants in Study 1, participants in Study 2 drank more days in the past month , drank more drinks on their peak drinking day  and had more heavy drinking days . Compared with participants in Study 2, more participants in Study 1 used cannabis in the past 6 months , χ21=12.6, P<.001 (N=835), and on more days in the past month , t100=5.01, P<.001. Approximately half of the participants reported any use of behavioral health services since their discharge, a little over a third reported use within the past year, and less than one-fifth reported use within the past month.Similar proportions of patients screened positive for PTSD  and depressive disorder . Participants consumed about 5 drinks per drinking day. Screening positive for an AUD was more likely for participants in Study 1  than in Study 2 , χt925=−7.4; P<.001) and per week  than participants in Study 2. However, participants in Study 1 spent more days per week playing video games than participants in Study 2 .Participants in Study 1 reported playing video games fewer hours per day  did not differ significantly from participants without any positive screen on video game behavior, while participants with either positive mental health screen  spent more hours per day and per week playing video games than those without a positive mental health screen . PoolingNo association was found between video game use and either any services receipt, mental health services receipt, or substance use services receipt within both studies. Pooling data across studies, participants with any positive screen for a behavioral health issue who had received any type of behavioral health services  since discharge from active duty spent 2.67 more hours per week (95% CI 0.14-5.20) and 0.48 more days per week (95% CI 0.14-0.82) playing video games than participants with any positive screen who had not received any type of behavioral health services since discharge. Participants with any positive SUD screen who had received any type of substance use services since discharge spent 0.75 more days per week (95% CI 0.28-1.21) playing video games than participants with any positive SUD screen who had not received any type of substance use services since discharge.We examined the video game playing behavior of two separate samples of young adult veterans recruited online. First, we found evidence across the two samples that most young veterans played video games: 54% of a general sample of young veterans and 74% of a sample of young adult veteran drinkers reported playing video games at least 1 hour per week. Next, among the video game players, we found that young adult veterans spent about 13-18 hours per week playing video games and about 2.5-3.5 hours per day playing video games. In a typical week, young adult veterans played video games on most days of the week. These findings suggest that video games might be a feasible intervention modality for young veterans generally and for behavioral health concerns specifically.While most analyses did not yield differences that were replicated across both studies, we did find several replicated differences in video game behaviors among young adult veterans depending on their screening positive for a behavioral health issue as well as their receiving services for a behavioral health need. Regarding screening positive for a behavioral health issue, we identified the strongest evidence for more hours per day and per week playing video games among participants with a positive screen for both PTSD and depression compared with those without positive screens for these conditions. Regarding the receipt of services for a behavioral health need, we identified the strongest evidence that participants who had a positive SUD screen and received substance use services since discharge spent more days per week playing video games than those with a positive SUD screen who had not received substance use services.Although most veterans in our sample played video games and those that did played quite often, our findings aimed to identify the potential groups of young adult veterans for the development and evaluation of video games as a modality for behavioral health services. Specifically, with respect to playing video games more per day and per week, young adult veterans screening positive for PTSD and depression may be more familiar with and dedicate more time to behavioral health services delivered via video games because these veterans already play more video games and more frequently than those without these issues and those not receiving services. For this population, relatively more intensive video game-based interventions might be acceptable. For example, previous research has demonstrated the feasibility of incorporating the core components of traditional cognitive behavioral therapies and exercise-based interventions for mental health into engaging, video games in Web-based, computer, console, and application-based formats ,23,40,41Several strengths and limitations are worth noting. Strengths of this study include replicating analyses from two independent samples to reduce the rate of false positives ,38; sharFindings suggest several avenues of future research as well as collaborations between researchers and video game developers. First, analyses from this study would benefit from direct, preregistered replications to strengthen the credibility of our findings. Direct assessment of acceptability and willingness to engage with video games for behavioral health services should be incorporated into this research . If our


Obtaining accurate information from a 112 caller is key to correct tasking of Helicopter Emergency Medical Services (HEMS). Being able to view the incident scene via video from a mobile phone may assist HEMS dispatch by providing more accurate information such as mechanism of injury and/or injuries sustained. The objective of this study is to describe the acceptability and feasibility of using live video footage from the mobile phone of a 112 caller as an HEMS dispatch aid.Live footage is obtained via the 112 caller’s mobile phone camera through the secure GoodSAM app’s Instant-on-scene™ platform. Video footage is streamed directly to the dispatcher, and not stored. During the feasibility trial period, dispatchers noted the purpose for which they used the footage and rated ease of use and any technical- and operational issues they encountered. A subjective assessment of caller acceptance to use video was conducted.Video footage from scene was attempted for 21 emergency calls. The leading reasons listed by the dispatchers to use live footage were to directly assess the patient (18/21) and to obtain information about the mechanism of injury and the scene (11/21). HEMS dispatchers rated the ease of use with a 4.95 on a 5-point scale (range 4–5). All callers gave permission to stream from their telephone camera. Video footage from scene was successfully obtained in 19 calls, and was used by the dispatcher as an aid to send (5) or stand down (14) a Helicopter Emergency Medical Services team.Live video footage from a 112 caller can be used to provide dispatchers with more information from the scene of an incident and the clinical condition of the patient(s). The use of mobile phone video was readily accepted by the 112 caller and the technology robust. Further research is warranted to assess the impact video from scene could have on HEMS dispatching. Major trauma is a leading cause of mortality and serious morbidity, especially in the young. Helicopter Emergency Medical Services (HEMS) attend the most severely injured trauma patients. For these patients, time is critical to save life and to prevent long-term disability –3. AccurIt is the HEMS-dispatchers’ role to obtain crucial information about the scene, the mechanism of injury and the clinical state of the patient(s) in a timely manner, in order to decide whether a HEMS team should be dispatched or not. This is challenging, as bystanders making an emergency call are usually not medically trained, and are often emotionally affected by what they witness. This can make it hard for them to describe complex scenes and/or the clinical condition of the patient(s) . DescripThe ability of a HEMS dispatcher and HEMS response team to view the scene in real time, at the point of the emergency call, could allow more accurate scene assessment and more appropriate, timely dispatch of emergency medical services, including HEMS. For this purpose, live video stream from scene is currently being trialed by Air Ambulance Kent Surrey and Sussex (AAKSS), allowing the AAKSS dispatcher to speak to the caller of the emergency number and ask whether they are in a position to stream live video footage from their mobile phone to the dispatcher in the control room.The objective of this study is to describe the acceptability and feasibility of the use of live video footage as a dispatch aid for HEMS dispatchers.This is a prospective study of all calls made to the emergency number (112/999) evaluated by the HEMS dispatchers of the Air Ambulance Kent, Surrey and Sussex between March and December 2018. AAKSS is a Helicopter Emergency Medical Service (HEMS) covering three counties in the southeast of England with a resident population of 4.5 million and transient population of up to 8 million. Two doctor/paramedic teams respond 24/7 in either a helicopter or response car, attending approximately 2500 missions per year. Statistics from the UK National Audit Office suggest that in this region of the UK, there are approximately 630 cases of major trauma annually.The AAKSS HEMS team  is dispatched by a dedicated AAKSS dispatcher who is present in the South East Coast Ambulance Service (SECAmb) control room, and continuously screens incoming emergency calls. AAKSS dispatchers have a background of ambulance dispatch, with extensive experience of working in the ambulance control room. As part of their HEMS dispatch training they are put through an induction course, followed by a four-week development period, starting with observation of the dispatch desk progressing to peer supervised practice and culminating in a sign-off assessment undertaken by an operational manager. All dispatchers observe regularly on operational shifts to improve awareness, and participate in the AAKSS (ongoing) internal audit process. Dispatchers are aided by a bespoke tasking algorithm, devised by the AAKSS management team . Whilst www.goodsamapp.org) platform, a globally used tool to task first responders to suspected out-of-hospital cardiac arrests [Video footage is streamed from scene to the control room using the GoodSAM  emergency call handing or ambulance dispatch. When video footage was used, HEMS dispatch was in accordance with the normal protocol assisted by the footage.Each time the dispatchers used live video footage from scene, the following characteristics were recorded by the dispatcher after the call: Ambulance call number, reason for use of video triage, type of individual asked to stream from scene , acceptability for the caller to use their camera to obtain footage as judged by the dispatcher (0–5), ease of use by dispatcher (0–5), specific variables around ease of use, any technical- or user issues, and the result of the use of the video footage (dispatch or no dispatch of HEMS team).Video footage was obtained under UK CCTV regulations for use. Callers were informed of the purpose of streaming live footage . Neither the video nor audio footage was recorded on the caller’s telephone or the receiving computer, as they were streamed on the Instant-on-scene™ app platform, which is confidential and compliant with the UK data protection act . This prDuring the study period, video footage from scene was obtained by the HEMS dispatchers for 21 emergency calls. The commonest reasons listed by the dispatchers to use the system were to assess the patient (18/21) and to obtain information about the mechanism of injury (MOI) and the scene (11/21). Most often a member of public was asked to stream from scene, although in a minority of cases the police (2) or an off-duty nurse (1) was asked to do so. In two cases patients themselves were asked to provide video footage . All callers who were asked permission to stream from their telephone camera were willing to do so. No caller refused to transmit live footage. All callers understood the instructions given by the dispatcher and received the SMS asking them their consent to share both their location and their phone camera. Video footage from scene was obtained for 19/21 calls. In two calls there was no data coverage, precluding video streaming from scene. One caller accidentally closed the call but continued streaming, and was called back by the dispatcher. The quality of the video stream was rated as good in 18/19 calls, and poor in 1/19. In one call there were audio issues, but this did not preclude the use of the footage as a dispatch aid.After watching the footage from scene, the dispatchers used the footage to confirm sending the HEMS team in 5/19 calls, whereas they decided not to send the team in the remaining 14 calls.In this pilot study, we demonstrated that live video footage from scene can be used to provide dispatchers with more information about the scene of an incident and the clinical condition of the patient(s), thereby assisting the HEMS tasking decision.We found that the platform used to obtain live video footage, the GoodSAM Instant-on-scene™, was easy to use for both dispatcher and caller, and was reliable in providing the desired footage, with technical issues occurring only in a small minority of the emergency calls it was used in. As the platform does not require installation of any specific apps on the callers’ phone, it can be used by almost anybody with a mobile phone, which means that the potential availability is considerable. Our data show that the willingness of the public to help by allowing access to their phone camera in order to stream video footage was high. In this regard it is important to mention that the caller was made aware of the fact that video footage is not stored on either end, and that the dispatcher cannot access any data on the caller’s phone. Furthermore, it should be noted that this study was carried out in a non-urban area. Willingness- and ability of callers to help may be lower in more urban areas, for example through the presence of language barriers.Since a bespoke tasking algorithm was used by our dispatchers , it was not used. Future studies are needed to investigate the contributive value of using live video footage and the effect it has on dispatch times. Furthermore, it is important to realize that when using live video footage as a dispatch aid, dispatchers and members of the public are asked to film and witness potentially shocking scenes they are not familiar with. So far, dispatchers have not experienced the snapshots of the scenes they witnessed as shocking. However, adequate support should be available to dispatchers, and offered to callers as well when needed. Finally, as the footage was used during daytime dispatches only in our study, we have no information yet about the quality of the video footage in more sparsely lit circumstances.In this initial feasibility study, video footage was used as a dispatch aid in 19 calls. In 5 instances, the dispatcher decided to send the HEMS team, whereas in 14 the HEMS team was not sent. It was beyond the scope of this feasibility study to determine whether the video footage contributed to a correct dispatch of HEMS. Although there are potential advantages of using live footage (more accurate dispatch), there may also be potential disadvantages. First, it is unclear what the influence of using live footage is on dispatch timings. Although the live video stream was established instantly in 19/21 cases in our study, it was not recorded how long streaming continued before the decision was made (not) to dispatch. Therefore, it is unclear how the dispatch times compares to the average (daytime) dispatch time of 10 min for the dispatches in the study period where live video footage was Live video footage from scene is an acceptable and feasible aid for HEMS dispatch. Further studies are needed to demonstrate its merit in improving HEMS dispatch accuracy and exploring potential for use more widely across ambulance services.


Hepatocellular adenomas (HCA) are benign liver tumors that may transform into hepatocellular carcinoma (HCC), but the molecular drivers of this transformation remain ill-defined. This study evaluates the molecular changes in HCA and HCC and in comparison to their adjacent non-neoplastic liver.11 patients with HCA and 10 patients with HCC without underlying hepatitis or cirrhosis were included in this pilot study. Tumor and non-tumor liver tissues were selected for immunohistochemical staining, small RNA sequencing, and targeted gene sequencing. We compared microRNA expressions and mutations between HCA and HCC and non-neoplastic liver.HCA were classified as inflammatory (n = 6), steatotic (n = 4), or β-catenin activated (n = 1) subtypes. MicroRNA profile of all 3 HCA subtypes clustered between that of normal liver and HCC in principal component analysis. In both HCA and HCC, miR-200a, miR-429, and miR-490-3p were significantly downregulated compared to normal liver, whereas miR-452, miR-766, and miR-1180 were significantly upregulated. In addition, compared to HCA, HCC had significantly higher expression of members of the chromosome 19 miRNA cluster (C19MC), including miR-515-5p, miR-517a, miR-518b, and miR-520c-3p.This study indicates that while there are significant differences in the molecular profile between HCA and HCC, several miRNAs are similarly deregulated in HCA and HCC compared to adjacent normal liver. These results may provide insights into the drivers of hepatocarcinogenesis and warrant further investigations. Hepatocellular adenomas (HCA) are rare, benign tumors from proliferation of hepatocytes in an otherwise normal-appearing liver, whereas hepatocellular carcinomas (HCC) are common, malignant tumors that frequently develop in a cirrhotic background –3. HCA mIn an attempt to better understand the drivers of transformation of HCA to HCC, we sought to explore unique molecular events in the adenoma-carcinoma sequence. To do so, we selected a group of HCA patients as well as patients with HCC but without hepatitis or cirrhosis, thereby excluding the “carcinogenic field-effect”-associated molecular alterations that may not be directly related to the adenoma-carcinoma sequence. However, despite the absence of background liver disease, it has been suggested that approximately 5 to 10% of pre-existing HCA may transform into HCC , 7. HCA There are 3 major molecular classifications of HCA: (a) β-catenin (CTNNB1)-activated HCA (B-HCA), (b) hepatocyte nuclear factor 1 α (HNF1α)-inactivated or steatotic HCA (H-HCA), and (c) inflammatory HCA (I-HCA) , 8, 9. AIn addition to studying somatic mutations in HCA and HCC through targeted gene sequencing, we also explored changes in microRNA (miRNA) expression. MicroRNAs are short (~21 nucleotide-long) noncoding RNAs that repress the expression of target genes by binding to 3’ untranslated region (3’UTR) of their transcripts and inducing their degradation and/or inhibiting their translation . BecauseThis study compares miRNA and genetic alterations between HCA and HCC, as well as their adjacent non-neoplastic liver, in patients without underlying hepatitis or cirrhosis.Patient data and specimens were collected with approval of the Memorial Sloan Kettering Cancer Center (MSKCC) Institutional Review Board (protocol HBS2013103). All patients had previously provided written consent to an institutional tissue procurement protocol for research. Eleven patients with HCA and 10 patients with HCC who underwent resection between 1999 and 2013 were included in this pilot study. None of the 21 patients had viral hepatitis, prior liver-directed therapy, or any evidence of cirrhosis. None of the HCC had fibrolamellar variant. Clinical and pathological information was collected through retrospective review of the medical records.Tumors were micro-dissected to isolate the area of interest before storage. All tissue samples were stored both as formalin-fixed paraffin-embedded (FFPE) blocks and snap-frozen in liquid nitrogen and stored at -80°C . RepreseRepresentative formalin-fixed paraffin-embedded (FFPE) blocks were obtained for each patient and immunohistochemical studies were performed on 4-μm sections according to standard protocols. HCA samples were immunostained with the following antibodies: β-catenin , liver fatty acid binding protein , serum amyloid A , C reactive protein , and glutamine synthetase . HCA with aberrant nuclear β-catenin expression were identified as β-catenin HCA (B-HCA), whereas HCA with loss of LFABP expression were considered as steatotic HCA (H-HCA), and HCA with expression of SAA and/or CRP were classified as inflammatory HCA (I-HCA) . ImportaFrozen tissue was homogenized in Trizol (Ambion) and total RNA extracted according to manufacturers’ instructions. High quality total RNA (1ug) was processed using the Truseq Small RNA Sample Preparation kit (Illumina). The 3’ and 5’ modified adapters were ligated specifically onto small RNAs and amplified for 14 cycles of PCR after reverse transcription. Barcodes were also introduced during the PCR steps. After size selection, the libraries were pooled and loaded onto a Hiseq (Illumina) sequencer for an SR50 run, using the TruSeq SBS Kit v3 (Illumina). An average of 11.5 million reads per sample were generated. To measure miRNA expression levels, a custom genome file of all microRNA sequences from miRBASE with the technology-specific adapter sequences was created as previously described . The seqhttp://www.cbioportal.org/study?id=hcc_msk_venturaa_2018#summary). HCA1 and HCA9 did not have IMPACT analysis. DNA from tumor and matched normal liver samples were subjected to sequence library preparation (Kapa Biosystems) and exon capture (NimbleGen). Barcoded sequence libraries were pooled at equimolar concentrations and input into a single exon capture reaction, as previously described[Genomic DNA from tumors and adjacent normal liver tissue was extracted using phenol/chloroform and subjected to analysis by a next-generation sequencing platform. Our institutional MSK-Integrated Mutation Profiling of Actionable Cancer Targets (MSK-IMPACT) assay was designed for targeted sequencing of all exons and selected introns of 341 oncogenes, tumor suppressor genes, and other potentially actionable targets –26. IMPAdescribed, 27. Poodescribed. Sampleshttp://www.R-project.org) and Bioconductor packages.Continuous and categorical variables were compared using Mann-Whitney U and Fisher’s exact tests, respectively. Unsupervised clustering of normalized miRNA levels was performed using classical multidimensional scale  function. Differential analysis of miRNA expression levels was performed using the limma package . MiRNA lTable 1). The HCC cohort included 10 patients with a median age of 73 years (range 63–81) and 40% were female. All patients developed HCA and HCC without viral hepatitis or cirrhosis.Eleven patients with HCA were included. Their median age was 40 years (range 24–56), 91% were female, and 64% had a history of oral contraceptive use  [To further classify HCA into known subtypes, we performed immunohistochemical and mutational analysis to established molecular markers as previously described , 9, 21. Table 2). Within the HCC cohort, the most common mutations were found in TERT (7/10), followed by TP53 (3/10), CTNNB1 (2/10), and APC (2/10). Several additional mutations were also identified in single tumors (S1 Table).Analysis of IMPACT assay identified 7 different mutations among HCA tumors and 41 different mutations among HCC tumors. The assay revealed that the most frequently mutated gene in our HCA cohort was HNF1α . HCA with HNF1α mutation, all of which belonged to the H-HCA subtype, stained negative for LFABP. A single HCA found to have a mutation in CTNNB1 and displayed abnormal β-catenin nuclear staining, was classified as B-HCA. In addition, we identified individual HCAs with mutations in GNAS, FAT1, HGF, PIK3CA, and MLL2 . Supervised clustering led to identification of 90 miRNAs that were differentially expressed between HCC and normal liver and between HCA and normal liver .MiRNA profile was compared between 10 patients with HCA and 10 patients with HCC, as one of the patients with HCA (HCA7 with H-HCA) did not have adequate tumor for miRNA sequencing. Unsupervised clustering of the miRNA profiles stratified by HCA and HCC and their normal liver using classical multidimensional scaling showed HCA samples clustering between HCC and normal liver in a low-dimensional space  (S3 Table). Nevertheless, both HCC and HCA had significantly lower expression of miR-200a, miR-429, and miR-490-3p compared to normal liver, and had significantly higher expression of miR-452, miR-766, and miR-1180 (Table 3).A total of 86 miRNAs were significantly dysregulated in HCC compared to adjacent normal liver  S4 Table). Notably, selected components of the chromosome 19 miRNA cluster (C19MC), including miR-515-5p, miR-517a, miR-518b, and miR-520c-3p, were amongst the top miRNAs differentially expressed between HCC and HCA or adjacent liver samples, with levels 3 to 4 folds higher in HCC samples .HCA were significantly different from HCC in the expression of 57 miRNAs  , followed by TP53 (3/10), and CTNNB1 (2/10), which were consistent with prior report . TERT prA role for the miR-200 family, including miR-200a and miR-429, in controlling epithelial mesenchymal transition (EMT) and metastasis is well established, including in the context of HCC , 33. A pIn this study, we found decreased expression of miR-490-3p in HCC and HCA compared to normal liver, which is consistent with the finding of one report but at odds with another , 35. ThiBoth HCA and HCC had significantly higher expression levels of miR-452 and miR-1180, both of which have been proposed to act as oncogenic miRNAs in HCC , 41. MiRMiR-766 was also found to be upregulated in both HCA and HCC compared to normal liver. MiR-766 overexpression has not yet been implicated in HCC or HCA, but it had been implicated in other cancers. MiR-766 was found to promote cell proliferation by targeting SOX6 in colorectal cancer, and its increased expression was associated with worse overall survival in patients with lung adenocarcinoma , 43.Members of a cluster of miRNAs on chromosome 19 miRNA (C19MC), including miR-515-5p, 517a, 518b, and 520c-3p, were significantly higher in HCC compared to HCA. C19MC is the largest miRNA cluster identified thus far, harboring 46 pre-miRNAs, and is located on chr19q13.41 , 45. TheIn this pilot study, we offer an unique perspective to evaluate and describe molecular changes in patients with HCA or HCC without underlying hepatitis or cirrhosis, thereby removing potential “carcinogenic field effect” . A majorIn conclusion, this study revealed while there are significant differences in the molecular profile between HCA and HCC, several miRNAs are similarly deregulated and are offering some support for progression in the hepatocellular adenoma-carcinoma sequence. In addition, HCC had higher expression of C19MC compared to HCA. Further validation using a larger sample size with more B-HCA samples and incorporating mechanistic investigations are warranted, as these miRNAs alterations have the potential to be used as surrogate marker to predict transformation from HCA to HCC.S1 FigRepresentative hematoxylin and eosin stain of HCA2 (A) with negative liver fatty acid binding protein (LFABP) stain (B) revealed that it is a steatotic HCA. Representative hematoxylin and eosin stain of HCA6 (C) with concomitant positive serum amyloid A (SAA) stain (D) and positive C-reactive protein (CRP) stain (E) revealed that it is an inflammatory HCA.(TIFF)Click here for additional data file.S2 FigThe x and y axis represent projections of the distances between the samples.(TIF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(PDF)Click here for additional data file.


To prepare for surgery, surgeons often recur to surgical videos, with YouTube being reported as the preferred source. This study aimed to compare the evaluation of three surgical trainees and three senior surgeons of the 25 most viewed laparoscopic appendectomy videos listed on YouTube. Additionally, we assessed the video conformity to the published guidelines on how to report laparoscopic surgery videos (LAP-VEGaS).Based on the number of visualization, the 25 most viewed videos on laparoscopic appendectomy uploaded on YouTube between 2010 and 2018 were selected. Videos were evaluated on the surgical technical performance (GOALS score), critical view of safety (CVS), and overall video quality and utility.Video image quality was poor for nine (36%) videos, good for nine (36%), and in high definition for seven (28%). Educational content  was rarely present. With the exception of the overall level of difficulty, poor consistency was observed for the GOALS domains between senior surgeons and trainees. Fifteen videos (60%) demonstrated a satisfactory CVS score (≥ 5). Concerning the overall video quality, agreement among senior surgeons was higher  than among trainees . The mean overall videos utility  was 1.92 (SD 0.88) for senior examiners, and 3.24 (SD 1.02) for trainee examiners. The conformity to the LAP-VEGaS guidelines was weak, with a median value of 8.1% (range 5.4–18.9%).Laparoscopic videos represent a useful and appropriate educational tool but they are not sufficiently reviewed to obtained standard quality. A global effort should be made to improve the educational value of the uploaded surgical videos, starting from the application of the nowadays-available LAP-VEGaS guidelines.The online version of this article (10.1186/s13017-019-0241-6) contains supplementary material, which is available to authorized users. Acute appendicitis is the most common abdominal emergency worldwide, with a lifetime risk of 8.6% in males and 6.9% in females . In moreLA is considered a basic procedure in the field of digestive surgery, and it represents one of the commonest interventions to begin surgical training in minimally invasive surgery. Indeed, this procedure can be safely carried out by surgical residents under the supervision of experienced surgeons , 11. MorTo prepare for surgery, surgeons recur more and more often to surgical videos with YouTube being reported as the preferred source , 13. BotTo amend this phenomenon, an international multispecialty trainers and trainees expert committee has recently published a consensus statement on how to report a laparoscopic surgery video for educational purposes  in order to achieve high-quality educational videos that could improve surgical training now on .The aim of the present study was to compare the evaluation of surgical trainees and senior surgeons of the 25 most viewed laparoscopic appendectomy videos listed on YouTube. Additionally, the video conformity to the LAP-VEGaS guidelines was assessed.https://www.youtube.com) on July 1, 2018, using the search terms “laparoscopic appendectomy” and “laparoscopic appendicectomy.” Videos were ordered by number of visualizations and the top 25 were selected based on the following criteria: videos uploaded between 2010 and 2018, live surgery recorded by laparoscopic camera, laparoscopic multiport intra-abdominal appendectomy, one LA procedure , videos made by professionals for professionals, patients aged > 12 years, and English language.A comprehensive search was carried out on YouTube  and three senior surgeons (> 100 hands-on LA)  expert iFor each selected video, we analyzed basic characteristics, educational content, surgeon’s laparoscopic performance, technical aspects, overall video quality and utility, and conformity to LAP-VEGaS guidelines Table .Table 1DTo evaluate the surgeon’s laparoscopic performance, the examiners applied the Global Operative Assessment of Laparoscopic Skills (GOALS) rating instrument , 21, whiThe three domains of the critical view of safety (CVS) score, originally developed for laparoscopic cholecystectomy , were moOverall video quality was scored as good, moderate, or poor. Overall video utility as an education/training tool for LA was rated using a 5-point Likert scale (1 useless to 5 very useful). Finally, one independent examiner (NdeA) assessed the conformity of each video to the 37 items composing the LAP-VEGaS guidelines .n) and percentages (%) for categorical variables and mean or median  for continuous and ordinal variables. Internal consistency between examiners was assessed through Cronbach’s alpha, where a value ≥ 0.7 was considered as acceptable. Spearman’s rho was calculated to assess the degree of correlation between performance measures. Binary logistic regression analysis was performed to identify factors associated with the overall video quality.Data analysis was performed with SPSS Statistics . Descriptive statistics were presented as frequencies  and not shown in 21 (84%). Concerning the trocars’ placement, there was a 100% agreement among senior examiners: 4 videos (16%) showed a correct trocar positioning, 6 (24%) an incorrect, and 15 videos (60%) did not show it. Among trainee examiners, the consistency was good , although they do not agree on all videos.Video quality was scored as good, moderate, or poor. Results are displayed in Table The mean overall videos utility was 1.92 (SD 0.88) for senior examiners and 3.24 (SD 1.02) for trainee examiners. The distribution among the different categories is shown in Fig. n = 24, 64.8%) were found in no video. The conformity to the LAP-VEGaS guidelines was very weak, with a median value of 8.1% (range 5.4–18.9%). The highest percentage of conformity was observed for videos #3, 4, and 17 (18.9%)  and dislikes .The LAP-VEGaS evaluation showed that all videos reported the surgical procedure in a step-by-step fashion (LAP-VEGaS item 17), and for all of them, the number of views and comments were available (LAP-VEGaS item 37). For 52% of videos, an audio or written commentary was provided in English (LAP-VEGaS item 26). However, the majority of the LAP-VEGaS items (n = 13) vs. poor quality (n = 12) videos. For 17/25 videos (68%), there was a 100% agreement among the three senior examiners. The remaining consensus was reached by discussion and a final grade  was attributed to the video. Then, we used binary logistic regression to evaluate the association between overall video quality and several video characteristics. The number of likes, the presence of audio/written, commentary, the utility score, and the LAP-VEGaS conformity were significantly associated with the probability of rating the video as moderate/good  with an adequate critical view of safety in 60% of cases. Trainees tended to overscore the surgeon’s proficiency in laparoscopy (GOALS score > 20 for 95% of videos) but they agreed on the CVS assessment. Overall, the level of difficulty of the displayed LA procedures was judged as low by both senior surgeons and trainees, with a very good agreement. This may not surprise considering the type of basic intervention that LA represents in general and digestive surgery and the selection that surgeons who uploaded their videos may do in order to share online only their best cases.The overall video quality was highly heterogeneous as well, as judged by senior surgeons or trainees. Only four videos 16%) were evaluated as poor, moderate, or good unanimously. Although the inter-examiner agreement was acceptable, this indicates how difficult is to judge the quality of a surgical video without a specific rating system. The same can be said for the overall video utility as an educational tool. In this case, trainees found the videos much more useful than senior surgeons, as expected by the lower level of experience (and the eager to learn) and the lower capacity to correctly evaluate the surgical technique. However, this also claims for caution in the use of popular domain videos as e-learning instruments for LA, as observed for other laparoscopic general surgery procedures, including laparoscopic cholecystectomy, fundoplication, or right hemicolectomy –17, 28. % were evAs laparoscopic videos are widely considered as a useful adjunct to operative training but most of them are found deficient in many aspects to be considered as an educational tool, the LAP-VEGaS guidelines on reporting a laparoscopic surgery video for educational purposes were published in 2018 [There are limitations in this type of study. We analyzed laparoscopic videos available on YouTube only. This is reported as the most popular video source, especially among surgical residents , but theVideos of laparoscopic surgery represent a useful and appropriate educational tool in digestive and general surgery, which should be implemented in the operative training. Recurring to public domain videos, most often on YouTube, is widespread and currently not regulated. Thus, a global effort should be made to improve the educational value of the uploaded surgical videos, starting from the application of the nowadays-available LAP-VEGaS guidelines.Additional file 1:Table S1. Conformity to the 37 items of the LAP-VEGaS guidelines. (DOCX 172 kb)


The amount of alcohol consumed during an occasion can be influenced by physical and social attributes of the setting, characteristics and state of individuals, and the interactions of these components. This systematic review identifies and describes the specific combinations and sequences of context-related factors that are associated with heavy drinking occasions.We conducted a systematic literature search of MEDLINE, Embase and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Eligible articles were event-level and event-based studies that quantitatively analysed associations of sequences or combinations of context-related factors with event-level alcohol consumption. We extracted information on study design, sample, variables, effect estimates and analytical methods. We compiled a list of combinations and sequences associated with heavier drinking  and with lighter drinking (‘protective contexts’). The review protocol was registered with PROSPERO (registration number: CRD42018089500).We screened 1902 retrieved records and identified a final sample of 65 eligible studies. Daily mood, day of week, location and drinking group characteristics are important drivers of whether an individual engages in a heavy drinking occasion. The direction and magnitude of some associations differed by gender, age, personality and motives, such that in particular social or physical contexts, some people may feel compelled to drink more while others are compelled to drink less. Very few sequences of factors were reported as being associated with event-level alcohol consumption.Contexts or factors are experienced in specific sequences that shape the broader drinking context and influence drinking behaviours and consequences but are under-studied. Event-level studies such as those using ecological momentary assessment can harness new technologies for data collection and analysis to improve understandings of why people engage in heavy drinking. Continued event-level research will facilitate public health interventions and policies that reduce heavy drinking and alcohol-related harms. Heavy drinking can result in harm at the individual, familial, community and societal levels –4. DrinkHeavy drinking patterns  involve consuming a relatively high amount of alcohol in a relatively short period of time , 11, 12.Event-level alcohol consumption refers to an individuals’ drinking pattern during a given occasion. An occasion typically refers to a day or evening, but may be more specific . Event-level alcohol consumption is distinct from measures of alcohol consumption across longer time-periods . Unless otherwise stated, hereafter ‘drinking’ refers to event-level alcohol consumption, ‘heavy’ or ‘heavier’ drinking refers to higher event-level alcohol consumption, and ‘light’ or lighter’ drinking refers to lower event-level alcohol consumption.According to a social ecological perspective of human behaviour , 6, 8–10Previous studies have focused on the independent effects of factors on drinking occasions and consequences  using methods such as ecological momentary assessment (EMA). The second is event-based studies, which collect data retrospectively about an event  or events . In theory, both designs allow the exploration of event-level associations between specific contexts and heavy drinking. However, their ability to comprehensively describe contexts and explore event-level associations between contexts and drinking varies.Two main types of studies have been used to investigate simultaneous and/or prospective relationships of context-related factors and individual-level factors with drinking. The first is Some event-level and event-based studies have identified specific combinations of factors related to drinking contexts and/or individuals that are linked to heavier drinking occasions among adolescents and young adults. For example, Thrul and Kuntsche found that the positive association between drinking with friends and heavier drinking was stronger among males than females . Lau-BarTo our knowledge, no review has comprehensively summarised the evidence on the specific contexts that are associated with heavy drinking. Further, we found no studies that comprehensively reviewed and discussed the design and methodology of these studies. A comprehensive review of the literature is needed to compile and summarise the specific contexts associated with heavy drinking patterns.To address these gaps, we conducted a systematic review which:Summarises the immediate contexts  and broader contexts (described by specific sequences of immediate contexts) that are associated with heavier drinking occasions. It provides a more comprehensive understanding of how contexts influence drinking, highlights gaps in understanding of contexts influencing heavy drinking and suggests opportunities for effective environmental approaches to reduce alcohol-related harms due to heavy drinking; andSummarises, critiques and proposes ways to improve the design and analytical methodology of the scientific literature that investigates event-level associations between contexts and drinking.A systematic review of English articles using MEDLINE, Embase and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases was conducted to identify eligible articles. The review protocol was registered with PROSPERO (registration number: CRD42018089500). The review was conducted in line with the PRISMA Statement  see S1  were thostatistically tested for differences in effect between groups of respondents described by combinations of factors , or it was possible to conservatively test via 95% confidence intervals, or reported the level of endorsement of responses in latent class analysis; andobserved a statistically significant difference (increase or decrease) in the outcome at the 95% confidence level , or heavy or lighter drinking endorsed by the majority of a class (>0.50 probability) in latent class analysis.Where studies presented both bivariate and multivariate estimates of a given association, only the effect estimates that are adjusted for potential confounding variables were extracted. For practical and conceptual reasons, qualitative studies and associations of factors with alcohol-related harms  were not eligible for inclusion in this review. Further details about the eligibility criteria are described in th of January 2018. A copy of the full search strategy is provided in The search strategy was designed in direct consultation with La Trobe University library staff with expertise in conducting systematic review literature searches. To ensure the search was highly sensitive to retrieving eligible records, we used a detailed list of search terms that describe alcohol drinking, event-level or event-based study design, and combinations, interactions or sequences. The search was conducted on the 29The process for screening records for eligibility is described in The following information was extracted by OS from the full text of each article included for review:Type of study design: e.g., EMA, daily diary study, TLFB survey, intercept survey, retrospective survey.Sample description: e.g., N; adult, student, patron of night-time precinct, drinker; country; age range.Outcome variable description: e.g., number of drinks consumed, breath alcohol concentration (BrAC), heavy drinking episode; continuous or categorical.Predictor variable(s) description: e.g., pre-drank, number of friends present, gender; continuous or categorical; event-level  or individual-level ; sequence or combination.Type and magnitude of effect estimate(s) and comparison statistic(s): e.g., difference in means or proportions between groups described by combinations of factors, odds ratio, beta-coefficient, interaction coefficient; p-value, 95% confidence interval, probability.Analytical approach used: e.g., multi-level modelling, person-mean centering of event-level predictors, latent class analysis, factor analysis or principal components analysis.Direction of association(s) : e.g., heavier drinking  or lighter drinking .The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies  was usedCombinations and sequences that were consistently associated with heavier drinking were compiled into a list summarising ‘risky contexts’ for men, for women and for either gender. Similarly, combinations and sequences associated with lighter drinking were compiled into a list of ‘protective contexts’ for men, women and either. Contexts were divided into categories that denoted whether the context was described by factors relating to the characteristics or state of the individual, physical environments and/or social environments. Specific combinations or sequences that were not unidirectionally associated with the outcome across studies  were dropped (see The flow of records throughout the screening process is presented in Characteristics of the studies included in the review are described in Five different types of study designs were included in the review. Eleven (17%) used a retrospective survey of a single previous drinking occasion, eight (12%) used a TLFB survey design, 14 (22%) used street interviews, 15 (23%) used daily diaries and 17 (26%) used an EMA design. Most studies  tested associations via multi-level modelling, accounting for the nested structure of the data, i.e., occasions (level 1) nested within individuals (level 2). Twenty-one studies (32%) used person-mean centered occasion-level predictor variables to aid interpretation of observed effects. Five studies (8%) constructed combinations of factors via latent class analysis or factor analysis.The study quality (risk of within-studies bias) for most of the studies were rated ‘good’ , 20 (31%) were rated ‘fair’, and one (2%) was rated ‘poor’.Most studies  derived an outcome from the number of drinks consumed during the drinking occasion or that day or evening, or from estimated blood alcohol concentration . Two studies (3%) combined total drinks consumed during the occasion with ratings of intoxication to derive an outcome measure for intoxication level. Thirteen studies (20%) derived outcome variables from the number of drinks consumed at specific locations/settings , until specific time-points  or during specific time-frames , or speed of consumption .The contexts that were found to be associated with heavier drinking are summarised in A total of 156 unique contexts were identified as being associated with heavier or lighter drinking. Of these, 110 contexts (71%) were associated with heavier drinking (labelled as ‘risky contexts’), and 46 contexts (29%) were associated with lighter drinking (labelled as ‘protective contexts’).Twenty-eight studies (43%) investigated the association between a sequence of event-level factors and event-level drinking, and 52 studies (80%) investigated the association between a combination of two or more context-related factors and event-level drinking. The number of studies that constructed sequences or combinations from factors from the following domains were as follows:individual characteristics/state only, 11/65 (17);physical environment only, 2/65 (3%);social environment only, 25/60 (38%);individual characteristics/state and physical environment, 7/65 (11%);individual characteristics/state and social environment, 21/65 (32%);physical environment and social environment, 8/65 (12%);individual characteristics/state and physical environment and social environment, 8/65 (12%).Most contexts were described from combinations or sequences of factors related to the individual  or social environment , exclusively or in combination with individual, social environment or physical environment factors. Fewer contexts were described from factors related to the physical environment, exclusively or in combination with individual or social environment factors . Twenty-four risky contexts and thirteen protective contexts  were described from a combination of factors related to all three elements of a context: the individual, the social environment and the physical environment.Negative or positive states of mood were found to be associated with heavier or lighter drinking depending on the individual’s traits and environmental characteristics that these emotions are combined with , 86, 93.The immediate social context was found to be most strongly associated with drinking behaviour when combined with certain individual characteristics. Heavy drinking occasions are more likely on occasions when many friends are present , 94, 96–Certain contexts appear particularly conducive to heavy drinking on weekends. Generally, spending time with friends, particularly in large groups of friends, is associated with heavier drinking , 79. On Some contexts experienced at a given time of the week are associated with lighter than usual drinking. Students who initiated drinking at an early age are less likely to engage in heavy drinking on weekend days if they are in a negative mood . Also, eIn particular circumstances, both public locations  and private places  may be conducive to heavy drinking. Occasions spent with groups of friends or in environments where many people are intoxicated were associated with heavy drinking regardless of whether they were in a public or private location . GeneralThere were three main sequences that are each found to be associated with heavy drinking: pre-drinking, yesterday’s alcohol consumption and multi-day accumulation of stress. Multiple studies found that heavy drinking was more likely on occasions involving pre-drinking than non-pre-drinking occasions –91, 98. Elements of contexts that were commonly associated with heavier or lighter drinking occasions included a person’s mood throughout the day, the size, gender and expectations of the social group, the location where drinking takes place, and whether certain events or parties are attended. However, the strength and direction of associations between context-level factors and drinking differ according to the characteristics of the individual . The variety of interactions among the elements of a context demonstrate the complexity of relationships between contexts and drinking behaviours. In fact, in a given social or physical context, some people may feel compelled to continue or accelerate their drinking, whereas others may be influenced to slow down, drink less, or choose not to drink at all. Therefore, it is important to consider the physical, social and individual elements of a context when endeavouring to understand contextual influences on people’s drinking. This is also an important consideration for interventions designed at the individual-level. Identification of contexts that are risky or protective for people of a particular gender and age and with particular personality traits and drinking motives may help to design and implement effective policies for reducing heavy drinking occasions and related harms among specific sub-populations.Identifying contexts that are associated with heavy drinking and contexts associated with lighter drinking is useful because it enables targeted interventions and policies, thus potentially reducing heavy drinking and alcohol-related harms. Concurrent discouragement of risky contexts  and encouragement of protective contexts (via the same avenues) may further reduce heavy drinking and alcohol-related harms.The search strategy retrieved 31 studies that are well-suited to measuring sequences of factors across an occasion (17 EMA studies and 14 intercept surveys). However, very few studies investigated links between specific sequences during an occasion and event-level drinking, aside from pre-drinking. It is also possible that some eligible studies that investigate sequences of factors during an occasion and event-level drinking were not captured by the literature search. One of the advantages of EMA studies is they can record the time of specific occurrences across the course of a drinking occasion . TherefoRelatively few contexts were described in relation to the physical environment. Research investigating whether and how physical contexts are associated with an individual’s drinking behaviour is needed because, in a practical sense, modification of the physical environment may be relatively feasible  . Technoland the physical environment. Future event-level studies that consider all the main elements that comprise a context have the potential to improve understandings of how and why specific contexts can influence drinking behaviour.A minority of the studies included in this review described contexts via a combination of factors related to the individual, the social environment Numerous types of event-level or event-based designs were used by the studies included in this review. However, their ability to comprehensively describe contexts and explore their associations with event-level drinking is varied.To accurately distinguish between the contextual influences at the event-level and the individual-level, studies which capture information about multiple occasions, such as EMA and daily diary studies are advantageous because they can properly account for both inter- and intra-individual variations using multi-level modelling , 105. StStudies with longer recall periods, such as retrospective surveys about single occasions and TLFB surveys, are more susceptible to recall bias .Event-level studies may harness new technologies such as smartphone environmental measurement tools and continuous objective monitoring of alcohol use to improve measurement of contextual factors and behaviours. Continuous objective monitoring of blood alcohol concentration in real time via objective measures such as transdermal sensors may reduce the risk of self-reporting biasing measurements of alcohol consumption and intoxication levels . SmartphThis review found that most studies that explore event-level associations between contexts and drinking were conducted among samples of adolescents and young adults, and often students. Therefore, many of the risky and protective contexts identified may generalise to younger populations, but not to older populations. The scope of this review was widened from young adults to all ages during the project conception and design phase, to attain a more-complete review of the relevant literature and to compare the representation of young samples and older samples in the literature on drinking contexts. The high representation of young samples in the literature appears warranted, given that heavy drinking occasions are most frequent and intense during late adolescence and early adulthood , 110. AlSimilarly, the results of this review may only generalise to broad Western populations, not to socio-demographically-defined sub-populations, which are known to vary in alcohol use and problems. Therefore, research investigating event-level associations between contexts and heavy drinking in specific sub-populations of both Western and non-Western countries is necessary.not pre-drinking is associated with lighter drinking’. Both interpretations are correct and provide a slightly different interpretation, although the former  is more intuitive and commonly reported. While in some cases it is possible to derive protective contexts by taking the reverse of the reported association , we chose not to do so because this is generally not how estimates are interpreted and explained in literature. Thus, the tendency for lower values to be a variable’s reference category/value may partly explain why fewer protective contexts were identified than risky contexts.The intuitive way to construct variables and interpret model estimates may partly explain why fewer protective contexts were identified than risky contexts. The reference category of a categorical variable or the lower value of a continuous variable typically corresponds with a lower level of exposure–e.g., a categorical variable for pre-drinking with reference category ‘no’ and comparison category ‘yes’. Also, the format of effect estimates of regression models  make it intuitive to interpret associations as the comparison category  versus the reference category –e.g., ‘pre-drinking is associated with heavy drinking’. The same effect estimate could also be interpreted as the reference category versus the comparison category–e.g., ‘This review identified many well-designed studies that investigated event-level associations between contexts and drinking using appropriate analytical methodology. However, some studies were highly susceptible to recall bias, and the absence of multi-level modelling in 18 studies meant some studies may not have properly accounted for between-person differences that may bias event-level effects , 105.Traditionally, most event-level and event-based studies of drinking contexts have focussed on describing independent associations between singular isolated context-related factors and drinking outcomes. This review excludes a section of the literature that does not conceptualise and measure contexts as combinations or sequences of factors. As drinking contexts are described by the complex interaction of factors related to the physical and social environment and the individuals within them , 6, 8–10This review found that the contexts an individual encounters on a given occasion are associated with how heavily they drink alcohol during that occasion. The direction and magnitude of these associations differ according to the gender, age, personality, motives and mental state of the individual, such that in a given social or physical context some people may feel compelled to continue or accelerate their drinking whereas others may be influenced to slow down, drink less, or choose not to drink at all. Contexts or factors are experienced in specific sequences that shape the broader drinking context and influence drinking behaviours and alcohol-related consequences across drinking occasions. However, risky contextual sequences are under-studied. Therefore, event-level alcohol research should prioritise improving understandings of the types and mechanisms of contextual sequences that are associated with heavy drinking and alcohol-related harms. New technologies such as smartphone environmental measurement tools and continuous objective monitoring of alcohol use and multi-level analytical methods are recommended to improve understandings of why people engage in heavy drinking. Continued research investigating event-level associations between contexts and heavy drinking will facilitate public health interventions and policies that reduce heavy drinking and alcohol-related harms.S1 Tablea Of submitted version of manuscript document; n.p.: Not possible ; (DOCX)Click here for additional data file.S2 TableDatabases searched: MEDLINE, Embase and the Cumulative Index to Nursing and Allied Health Literature (CINAHL); Searched titles and abstracts of records; The above search terms were applied in MEDLINE, and replicated in Embase and CINAHL (via some minor adjustments); Search limits: Exclude MEDLINE records (applied to Embase and CINAHL searches only); Executed search strategy and retrieved articles on 29 January 2018.(DOCX)Click here for additional data file.S3 Table1 Must include at least one context-level variable and must not include event-level alcohol consumption (the outcome); 2 Compared to the reference categories of categorical variables and/or the lower values of continuous variables (unless inverted or transformed), as derived by the authors; ‘Today/yesterday’: event-level variable; ‘Generally’: Individual-level variable; Single factor + arrow in ‘all’ column: sequence; All: among sample of men and women combined; Single factor + arrow in gender column: effect of that single factor greater for that gender than the other gender  (does not refer to effect of one factor among sample of women or men); Combinations/sequences allocated to the most relevant subsection according to the types of factors involved .Heavier drinking: Higher event-level alcohol consumption; Lighter drinking: Lower event-level alcohol consumption; (DOCX)Click here for additional data file.S1 File(PDF)Click here for additional data file.