This study examined sociodemographic, physical and mental health, and adult and childhood adverse experiences associated with binge drinking in a representative sample of women in the State of California.Data were from the 2003 to 2004  California Women's Health Survey (CWHS), a population-based, random-digit-dial annual probability survey sponsored by the California Department of Health Services. The sample was 6,942 women aged 18 years or older.The prevalence of binge drinking was 9.3%. Poor physical health, and poorer mental health , were associated with binge drinking when demographics were controlled, as were adverse experiences in adulthood  and in childhood . When adult mental health and adverse experiences were also controlled, having lived as a child with someone who abused substances or was mentally ill was associated with binge drinking. Associations between childhood adverse experiences and binge drinking could not be explained by women's poorer mental health status in adulthood.Identifying characteristics of women who engage in binge drinking is a key step in prevention and intervention efforts. Binge drinking programs should consider comprehensive approaches that address women's mental health symptoms as well as circumstances in the childhood home. Binge drinking has been linked to a broad range of health and psychosocial problems. Although definitions of binge drinking vary somewhat among studies, a commonly used definition for women and men is that of the Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System: five drinks per drinking occasion at least once during the past 30 days. Rates of binge drinking are lower among women than men across different age and racial/ethnic groups -3. The rIt is important to understand the determinants of binge drinking among women because higher rates of binge drinking are linked to increases in alcohol use disorders, injuries and other alcohol-related health problems , psychosocial problems, and high-risk behaviors  . This stA number of studies have examined sociodemographic factors associated with women's binge drinking. Binge drinking is more common among younger (<30 years) women  and bingFemale victims of violence often engage in self-destructive and maladaptive coping behaviors, including binge drinking. Increased rates of domestic violence among women were associated with increased binge drinking rates . SimilarAdverse experiences in childhood also increase the risk for the subsequent problematic use of alcohol such as binge drinking. Childhood sexual abuse was an important predictor of alcohol misuse and binge drinking among adult women ,15, and Although adverse childhood experiences have been found to be associated with problematic alcohol use such as binge drinking, studies have not examined whether the childhood events are associated with alcohol misuse even when adult life events and circumstances are also considered. In addition, they have not examined whether poor mental health as an adult mediates the link between adverse childhood experiences and adult binge drinking, as some have hypothesized . Both ofIn summary, in this study we asked the following questions: (1) What is the rate of binge drinking in a representative sample of women in the State of California, (2) What are the sociodemographic, physical and mental health, and adverse adult and childhood experiences associated with binge drinking, (3) Are adverse childhood experiences associated with binge drinking, even when adverse adult experiences and mental health symptoms are already accounted for, and (4) Does poorer adult mental health mediate the association between adverse childhood experiences and adult binge drinking among women.All procedures for this study were reviewed and approved by Stanford University's Institutional Review Board. We used data from the 2003 and 2004 California Women's Health Survey (CWHS), a population-based, random-digit-dial (not including cell phones) annual probability survey sponsored by the California Department of Health Services and designed in collaboration with several other state agencies and departments. Interviews for the CWHS are conducted in English or Spanish and take approximately 30 minutes to complete.The response rates for the surveys  were 72% and 74%, respectively. The combined 2-year sample consisted of 6,942 women aged 18 years or older. More detailed information about the sample procedures can be found in [Respondents were asked: Considering all types of alcoholic beverages, how many times during the past month did you have five or more drinks on an occasion? Following the CDC definition used prior to 2006, respondents who reported doing so one time or more were classified as binge drinkers; all other respondents, including abstainers, were classified as non-binge drinkers.Respondents reported their age, race and ethnicity, marital status, whether children were in the household, education, and employment status. Respondents' reports of household size and annual household income were used to determine whether they were above or below the federal poverty line .The interview asked: To your knowledge, are you now pregnant (yes/no). It also asked: Do you now smoke cigarettes. Answers were classified as yes (every day or some days) or no . Respondents' self-reported health was classified as good  or fair/poor.Symptoms of PTSD were assessed using a five-item screen, demonstrated by Prins et al.  to detecPoor mental health was assessed by asking respondents to report how many days during the past 30 their mental health  was not good. Respondents were coded positive for poor mental health if they reported that their mental health was not good on ≥14 days. In addition, respondents reported whether they had wanted or needed help with personal or family problems from a mental health professional in the past 12 months (yes/no), and whether they had obtained such help (yes/no).CWHS questions on adverse adult and childhood experiences were from the Traumatic Stress Schedule, a validated self-report measure of traumatic events , and subRespondents reported whether they experienced the following adverse experiences during their childhood (before age 18): was removed from home and placed in foster care; lived with someone who was a problem drinker or alcoholic or used street drugs; lived with someone who was depressed or mentally ill; mother or stepmother was treated violently; lived with someone who went to prison or jail; emotional abuse ; physical assault ; and sexual assault .The first set of logistic regression analyses examined associations of sociodemographic factors (each entered singly as an independent variable) with binge drinker status. Then, we conducted logistic regression analyses that controlled for the sociodemographic factors found to be significantly associated with binge drinking, and entered one factor  in the domain of physical health, mental health, mental health help, adverse adult experiences, or adverse childhood experiences as a predictor. A third set of logistic regressions examined associations of adverse childhood experiences with binge drinking when sociodemographic, adult mental health, and adverse adult experiences that were significantly associated with binge drinking were controlled; the purpose was to determine whether adverse childhood experiences were independently associated with binge drinking after more recent adverse experiences and mental health symptoms as adults were considered. Finally, we conducted a series of regression analyses to determine whether poorer adult mental health mediated between adverse childhood experiences and binge drinking.The prevalence of binge drinking was 9.3%. The other sample characteristics are presented in Table Logistic regressions predicting binge drinking from current physical and mental health, and help for mental health problems in the past year, found a significant association for each factor Table . SpecifiB = -.272, OR = .762, CI = .63–.72, Wald X2 = 9.14, df = 1, p = .003) and by having lived with someone mentally ill  in predicting binge drinking were significant. There were positive associations of poor mental health and having lived with someone mentally ill with binge drinking in each age group except for the oldest group. That is, among women 65 years old or older only, poor mental health and having lived with someone mentally ill were associated with non-binge drinker status.Because, as already noted, binge drinking is more common in younger age groups, we examined whether age was a moderator of associations between physical and mental health, mental health help, and adult and childhood adverse experiences and binge drinking. Specifically, we conducted each logistic regression in Tables We examined whether adverse childhood experiences were still associated with binge drinking when mental health  and adverse experiences  in adulthood were controlled Table . When adFinally, we examined whether poor mental health as an adult mediated associations between adverse childhood experiences and adult binge drinking. First, we created two new dichotomous variables reflecting adverse childhood experiences: (1) lived with a person who abused substances and/or was mentally ill and/or a mother victimized by violence (50.3%) or not, and (2) was emotionally abused, physically assaulted, or sexually assaulted (33.7%) or not. Regressions showed that living with a disordered/victimized person predicted binge drinking, as did childhood abuse/assault Table .To examine mediation, first, poor mental health  was the dependent variable in regressions using the new variables as predictors. Living with a disordered or victimized person was associated with poor mental health, as was having been abused or assaulted Table . As alreThe CWHS found that the prevalence of binge drinking among adult women in California was 9.3%. This is similar to findings from national surveys of the US population in which 7.3% to 11.8% of women reported drinking five or more drinks on an occasion in the past month ,23,24.Compared to women who did not binge drink, binge drinking women were less likely to be pregnant, and more likely to smoke cigarettes and to describe themselves as only in fair or poor health. These results agree with those from other studies that pregnancy is associated with less binge drinking whereas smoking is associated with more binging on alcohol ,26. One We found that about 13%–14% of the women in this sample had symptoms of depression or overwhelming stress, whereas symptoms of PTSD were less common and symptoms of anxiety were reported by 22% of women. Having symptoms of depression, stress, PTSD, and anxiety were each associated with binge drinking. The association between depression and alcohol misuse has been relatively well-documented in the literature. For example, analyses of the Canadian National Population Health Survey found an association of major depression and binge drinking among women . In a saAs expected, binge drinking was associated with adverse experiences both in adulthood and in childhood. For adult victimization by intimate partner violence or sexual assault in particular, drinking is often a maladaptive means of coping with the traumatic aftermath -34. WhenVictimizing childhood experiences have been consistently linked to problems in childhood that extend into adulthood -41. For Even after adulthood factors were considered, the childhood experiences of having lived with someone who abused substances (22.3% of the sample did so) or who was mentally ill (16.8% did so) were still associated with binge drinking. Problematic alcohol use is known to be influenced by problematic parental drinking and a family history of alcoholism . While aImportantly, we found that adverse childhood experiences represented by living in the midst of others' or one's own difficult life circumstances retained independent associations with women's binge drinking and was not mediated by poorer mental health status in adulthood. Thus it may not always be enough to intervene only with binge drinking, or even with the depression and anxiety also associated with binge drinking. Rather, providers working with binge drinkers should consider asking whether adverse childhood experiences have occurred , and then addressing any consequences of such adverse experiences if they have taken place. Research on trauma-focused therapy for women who were victimized in childhood that has shown promise for improving mental health symptoms -54 needsThe findings must be considered in light of the methods used. The definition of binge drinking was based on a quantitative cut point that did not consider individual factors that affect blood alcohol concentrations . Although a clinically-focused definition  may have produced different results, consuming five or more drinks on a single occasion usually results in intoxication and impairment .Self-reports as used here may somewhat underestimate alcohol consumption compared with diagnostic interviews, but they typically provide more accurate data than laboratory tests and collateral reports . The datIdentifying characteristics that are commonly found among women who engage in binge drinking is a key step in designing and implementing effective prevention and intervention efforts. Binge drinking prevention programs perhaps should attend to adult mental health symptoms as well as dynamics in the childhood home. Experts working to decrease binge drinking may consider screening for addiction and other psychiatric disorders reported in the childhood home as well as other types of adverse childhood experiences and then addressing the trauma and other consequences of those stressors. Findings that childhood abuse is associated with poor substance use disorder treatment outcomes in adulthood  underscoThe authors declare that they have no competing interests.All the authors contributed to the design of the study and the analysis and interpretation of data, RK and JP helped to design and acquire data from the CWHS, CT managed the literature searches and wrote the first draft of the manuscript, AS managed the analyses. All authors contributed to and approved the final manuscript.


Because mobile telephones may support video calls, emergency medical dispatchers may now connect visually with bystanders during pre-hospital cardio-pulmonary resuscitation (CPR). We studied the quality of simulated dispatcher-assisted CPR when guidance was delivered to rescuers by video calls or audio calls from mobile phones.One hundred and eighty high school students were randomly assigned in groups of three to communicate via video calls or audio calls with experienced nurse dispatchers at a Hospital Emergency Medical Dispatch Center. CPR was performed on a recording resuscitation manikin during simulated cardiac arrest. Quality of CPR and time factors were compared depending on the type of communication used.P=0.048), but the median time to first compression was not shorter . The median time to first ventilation was insignificantly shorter in the video-call group . This group also had a slightly higher proportion of ventiliations without error .The median CPR time without chest compression (‘hands-off time’) was shorter in the video-call group vs. the audio-call group  significantly without proper training of dispatchers and when using dispatch protocols written for audio-only calls. Improved dispatch procedures and training for handling video calls require further investigation. Dispatchers in centers with technology allowing reception of video calls from the public may have more information from the scene of accidents and other medical emergencies. If dispatchers are enabled to see patients, bystanders and rescue attempts, the information may help dispatchers plan and coordinate resources, and possibly improve instructions given to the caller. Little is known about how this technology would influence outcome.VStandard protocols for telephone CPR-instructions (t-CPR) have been developed and tested, and national and international protocols for t-CPR are being used currently.6We hypothesized that video communication could improve the quality of lay people CPR by enhancing communication between bystanders and dispatchers during t-CPR. In a previous study, we found that video communication can improve dispatchers’ understanding of the rescuer's situation and improve the guidance they provide.Students from three different high schools in Tromsø, Norway, volunteered as lay bystanders. We used high-school students, because they adapt more quickly to new mobile phone technology and represent the future users. We also wanted to avoid that the mere use of communication technology would disturb resuscitation attempts. We, therefore, divided the students into groups of three to allow two persons for CPR while the third person took care of communication with the dispatch center.The study population was selected during regular school hours without prior warning. All students gave informed consent. Twenty groups participated each day, totaling 180 students in 60 groups. Six experienced nurse dispatchers were recruited from the University Hospital Emergency Medical Dispatch Centre (AMK-Tromsø). Two dispatchers participated each day, performing 10 sessions of t-CPR each during the study. We randomly selected the first dispatcher and the first communication mode tested each day. The dispatcher and communication mode were switched for each session. Trials were performed during December 2006 and January 2007. The study was accepted by the Norwegian Social Science Data Services.Rescuers communicated either via mobile phone audio calls on a Sony Ericsson K800i  or via combined audio and video calls on a Nokia N90 mobile telephone . To improve the ecological validity of the study, the default audio setting was used for each mode. The loudspeaker function was activated by default when instructions were delivered via the Nokia N90 video phone. When t-CPR instructions were delivered via the audio-only mobile phone (K800i), the loudspeaker function was not used. We thus studied ‘loudspeaker video’-assisted instructions compared with non-loudspeaker audio-call instructions.When delivering audio-call instructions, dispatchers used a telephone with a standard headset. For video-call instructions, dispatchers used a laptop with a UMTS (3G) card, video camera, video communication software  and a standard headset. The mobile network service provided video calls with the 3G-324M protocol, with a maximum speed of 64 kbit/s during the study period.During video calls, the caller could see the dispatcher on the phone's small color screen. The phone's camera could be pointed by the caller, and this image was seen by the dispatcher, who could also ask the caller to reposition the phone camera. In most cases, the dispatcher would want to see the manikin and actions of resuscitation carried out by the two others in the group of three.During audio calls, the caller was expected to convey all information to the other two team members as is normal procedure when several persons perform t-CPR.Dispatchers used the national Norwegian criteria-based dispatch protocol updated to recent CPR protocols,We used a standard training manikin to simulate cardiac arrest . Each student group was given a written description of the simulated emergency  and 17.3 years in the video group (range 15–34 years). 34.4% of the participants in the audio group and 26.7% in the video group were males. Seventy one percent of the students in the audio group and 73% in the video group had some kind of CPR training during the last 3 years. One male and five female dispatchers, with a mean age of 33.5 years (range 28–51 years), provided telephone CPR instructions.Video recordings carried out during the trial show that dispatchers adapted their instructions based on the input they receive from the rescuers. During video calls, dispatchers often responded to what they saw, clarified misunderstandings or gave more detailed instructions when they saw that rescuers did not perform as they wanted. Verbal support was often provided on how to open the airway and how to perform ventilations when they saw rescuers struggling with these procedures.During the 60 cardiac arrest simulations, five cases had neither chest compressions nor ventilations registered by the recording manikin: one during video and four during audio sessions. Video recordings showed that students in these five scenarios believed that the manikin was breathing, and in cooperation with the dispatcher nurse, placed the manikin in the recovery position without attempts of resuscitation. Among the remaining scenarios, there were another four cases where no ventilations were registered: one during video and three during audio sessions. Our video recordings for these four scenarios show that students attempted ventilations, but failed to open airways.P=0.048). No significant differences between video and audio groups were found for the other variables of CPR quality. A contributing factor was that a large number of groups were unable to perform any of the CPR tasks correctly. The best performers of ventilations during video calls were, however, noticeably better than the best performers during audio calls (io calls .Bystander CPR in dramatic pre-hospital situations is frequently supported by telephone-mediated advice from medical dispatch centers. Misunderstandings, language barriers and severe stress may distort communication between the two parties when ‘blind’ communication by phone is their only link. Dispatchers reported video communication as an improvement in such settings.However, the video groups had a significantly shorter hands-off time. This is in line with suggestions by some of the dispatchers.During audio calls, more groups failed to identify respiratory arrest or failed to open the airway. We believe this was caused by dispatchers using the images for more targeted instructions for airway opening and ventilations. The same observations may explain why our data indicate that video calls may improve the quality of ventilations for some rescuers .Dispatchers had no training in the use of video communication in this setting, and had to discover the potentials and limitations of the technology themselves. We also used a criteria-based dispatch protocol designed for audio-only t-CPR. This might have limited the positive findings during video communication.Proper use of health information systems often requires a socio-technical approach that deals with technical and organizational issues.The mobile video telephones and the network bandwidth used during this study did not allow very high-quality picture, and dispatchers noted that pictures were often inadequate to identify the details of CPR performance.Most witnessed cardiac arrests occur in the home where the presence of several potential rescuers is unlikely,We studied high school students, a population more likely to adapt to the use of new mobile technology, but not a risk population for cardiac arrest. However, only those who know how to use video phones will be likely users during medical emergencies. In the future, when more people are accustomed to video conferencing through mobile phones, this limitation would not apply.This study does not support implementing routine use of video calls from mobile phones when the public communicates with dispatch centers during CPR. Our study was limited by the low-quality video received from phones, and lack of prior training of dispatch personel in using video calls. Further studies may demonstrate improved clinical outcome for video calls, given such improvements. We conclude that current video communication is unlikely to improve t-CPR significantly without proper training of dispatchers and with dispatch protocols written for audio-only calls.


Congou, a grade of Chinese black tea, may protect against cancers of the oesophagus and reduce the risk of a combination of alcohol drinking and smoking , regardless of temperature when drinking.The study from a large hospital-based case–control for 1248 cases with oesophageal cancer and the same number of controls in South China showed that British Journal of Cancer (2002) 86, 346–347. DOI: 10.1038/sj/bjc/6600054www.bjcancer.comThe Cancer Research Campaign© 2002  Aetiological study is infrequent here. Congou is a grade of Chinese black tea, which is habitually drunk at a very high temperature by much (over 80%) of the population in the locality. Concerning the association with tea, several epidemiological and laboratory studies have suggested a protective effect of tea , sex, and same hospital but who had no diagnosis of tobacco and/or alcohol-related diseases.Congou tea ; alcohol drinking ; and tobacco smoking . Smoking and dietary habits were assessed in the period just before 10 years before admission to the hospital. A food frequency questionnaire was used to assess the consumption of the various food items. The 12 food groups used in the study questionnaire were included, i.e., sowbelly, kipper, pickled vegetable, smoked food, fermented fish sauce, vegetables, fresh fruits, fresh meat, eggs, cereals, fats, and dairy products. The case–control had been described elsewhere.The same questionnaires for cases and controls were completed by eight trained medical students. Information was collected on occupation, socioeconomic status (income and education); on the lifetime habits of drinking An unconditional analysis was carried out because it is generally accepted that in a matched study, this analysis can be performed if appropriate adjustment is made for matching variables which in this study were sex, age, and hospital. Moreover, the results obtained with the conditional analysis were practically identical to those obtained with the unconditional one. Both sexes were combined in statistical analysis.Congou drinking) and the same amount of controls were included in the study. Unconditional logistic regression analysis with stepwise forward selection  of variables showed that those with risk effect were older age, male sex, rural inhabitant, farmer or fisher occupation, lower income, consumption of tobacco, alcohol, fermented fish sauce, pickled vegetable, and sowbelly. Those with protective effect were fresh fruit, cooked vegetable (but lack of dose–response relationship), and Congou drinking. An analysis for Congou or hot Congou drinking after adjustment for age, sex, region, occupation, income, alcohol, tobacco, fish sauce, pickled vegetable, sowbelly, fruit, and vegetable were carried out. Table 1Congou and hot Congou.A total of 1248 cases (median age 58.5 (range 29–82) years, 936 males, 312 female, 85% with habit of For further analyses, cigarette smoking was divided into non-smoking and current smoking (one cigarette per day or more) after the ex-smokers were excluded. Alcohol drinking groups were divided into either daily or not-daily (three times per week or less) types. In Table 2Congou, Congou, or hot Congou drinking , 6.82 (95% CI: 3.91–11.9), and 5.29 (95% CI: 2.45–11.4) for non-Congou, Congou, or hot Congou drinkers, respectively (Congou and hot Congou groups, compared with corresponding figure in Thus, the joint effect of alcohol drinking and smoking was a synergy observed in three groups, i.e., non-These results of the present study provide epidemiological support for the hypothesis that tea, regardless of its temperature when drinking, may protect against cancers of the oesophagus, although results from studies that had shown an effect of drinking scalding hot liquids may indicate that the protective effect of tea could be reduced or eliminated (The results from epidemiology are not consistent, but laboratory studies have indicated that tea has inhibitory effects against tumour formation and growth, for example, the caffeine constituent of black tea has been found to be protective against carcinogenesis for several cancers of a tobacco-specific nitrosamine-NNK in bd-ix rats (


Thus these follicle-like portions in adult and aged thymus were considered to be functioning as cortex as in infant thymus. Proliferative activity of thymocytes in the thymic cortex and the follicle-like portions definitely declined with advance of age, while incidence of apoptotic thymocytes increased with aging.Normal human thymuses at various ages were immunohistologically examined in order to determine whether adult or aged thymus maintained the microenvironment for the T cell development and thymopoiesis was really ongoing. To analyze the thymic microenvironment, two monoclonal antibodies (MoAb) were employed. One is MoAb to IL-1 receptor (IL-1R) recognizing medullary and subcapsular cortical epithelial cells of normal infant human thymus. The other is UH-1 MoAb recognizing thymic epithelial cells within the cortex, which are negative with IL-1R-MoAb. Thymus of subjects over 20 years of age was split into many fragments and dispersed in the fatty tissue. However, the microenvironment of each fragment was composed of both IL-1R positive and UH-1 positive epithelial cells, and the UH-1 positive portion was populated with lymphocytes showing a follicle-like appearance. Lymphocytes in these follicle-like portions were mostly CD4


The European region has the highest levels of alcohol consumption in the world. Within Western Europe, the UK has one of the highest levels of binge drinking, and Scotland had the steepest increase in liver cirrhosis mortality rates  during the 1990s.There are relatively few studies of drinking patterns in the UK. Existing surveys have tended to sample participants from a narrow age range, and have restricted measures of alcohol consumption which typically focus on average consumption as opposed to drinking patterns. The present study compared the prevalence of three measures of potentially hazardous drinking  among men and women using repeat measurement within a longitudinal survey of three age cohorts. The study asked three questions: Are there gender differences in hazardous drinking? If so, are they equally large at two time points (1990 and 2000)? Are they equally large in three cohorts?Participants were drawn from the West of Scotland Twenty-07 study, a longitudinal study of the health of three age cohorts, in which a detailed questionnaire is administered by trained nurse interviewers approximately every 5 years.The Twenty-07 study provides detailed information on alcohol consumption. As well as standard scales, it contains a 7-day recall grid which allows the calculation of weekly and daily drinking. Responses were converted to standard units equivalent to 8 g of pure alcohol . For context, the proportion of participants who currently drink alcohol and the mean number of units of alcohol consumed in the last week are reported. The main outcomes are three measures of hazardous drinking: heavy drinking  and Wave 4 (beginning in 2000) of data collection. Wave 2 was used as the starting point as this was the first time that the youngest cohort were legally allowed to consume alcohol. In 1990, data were available for 636 men and 705 women in the youngest cohort , 541 men and 673 women in the middle cohort , and 576 men and 680 women in the oldest cohort . All study members who had data available for either Wave 2 or Wave 4 were included in this study. Response rates for Wave 4 were 63.3%, 78.3% and 78.1% for the youngest, middle and oldest cohorts, respectively.Men's levels of overall alcohol consumption and hazardous drinking (according to the three indicators) were substantially higher than women's levels in all three cohorts in both 1990 and 2000 . DespiteChanges in the ratio of the percentage of male:female drinking suggested that gender differences in heavy drinking reduced over the decade for each cohort; this was because the proportion of men classed as heavy drinkers reduced slightly between 1990 and 2000, while levels for women increased slightly. There was little consistent pattern for binge or problem drinking. For heavy and binge drinking, male:female ratios were smallest in the youngest cohort and largest in the oldest cohort; for example, twice the proportion of men that women reported binge drinking in the youngest cohort, compared 11 times the proportion in the oldest cohort. However, gender differences in problem drinking (an indicator of drinking dependence) were smallest in the middle cohort.Looking across generations, the youngest cohort had substantially higher levels of binge drinking than other cohorts; in 1990, 47.2% of men in the youngest cohort were classed as binge drinkers compared with 34.6% of men in the middle cohort and 17.2% of men in the oldest cohort. The comparable differences between women were even more striking: 21.7%, 8.8% and 1.5% in the youngest, middle and oldest cohorts, respectively. It was also notable that a higher proportion of respondents in the youngest cohort reported binge drinking rather than heavy drinking at both time points, suggesting that heavy episodic drinking was more common in this cohort than alcohol consumption which was more evenly distributed across the week.Overall alcohol consumption and levels of hazardous drinking remained much higher among men than women. Rather than women drinking like men,However, these data also indicate that some concern about young women's drinking is justified. Gender differences were generally smallest in the youngest cohort, and recent data from other studies suggest a further narrowing of gender differences in heavy drinking among teenagers.Another limitation of these data, common to all longitudinal studies, is attrition which, although generally lower in the present cohorts than in other studies, raises concerns about selection bias. In order to investigate whether hazardous drinkers were more likely to drop out of the study, drinking outcomes at Wave 2 were compared for those who responded at Wave 4 with those who did not respond. Statistically significant differences were only found for the oldest cohort. The main analysis was repeated using only the subgroup of participants who responded at both Wave 2 and Wave 4. While the prevalence of binge and problem drinking reduced slightly for men and women in the oldest cohort in 1990, the conclusions were essentially unchanged (results available upon request). This study also has a number of strengths, including its sampling which draws on a general population, very detailed assessment of drinking behaviour and the serial measurement of study participants.The current advertising campaign to reduce binge drinking in England is aimed at those under 25 years of age.


In a case–control study, However, drinking water data for Cape Cod suggest additional exposures that are relevant to this analysis. An alternative, or possibly additional, explanation for the elevated breast cancer risk may be drinking water exposures to volatile organic compounds (VOCs), some of which are mammary gland carcinogens . AlthougAn unspecified number of BWPCF-exposed participants relied on private wells, which were probably not affected by the airport. However, from 1970 to 1990, only around 10% of homes near the BWPCF relied on private wells , so mostA further complication is that Despite uncertainty about the composition of drinking water exposures,


Electronic patient records are becoming more common in critical care. As their design and implementation are optimized for single users rather than for groups, we aimed to understand the differences in interaction between members of a multidisciplinary team during ward rounds using an electronic, as opposed to paper, patient medical record.A qualitative study of morning ward rounds of an intensive care unit that triangulates data from video-based interaction analysis, observation, and interviews.Our analysis demonstrates several difficulties the ward round team faced when interacting with each other using the electronic record compared with the paper one. The physical setup of the technology may impede the consultant's ability to lead the ward round and may prevent other clinical staff from contributing to discussions.We discuss technical and social solutions for minimizing the impact of introducing an electronic patient record, emphasizing the need to balance both. We note that awareness of the effects of technology can enable ward-round teams to adapt their formations and information sources to facilitate multidisciplinary communication during the ward round. Electronic patient records (EPRs) are progressively being implemented in many hospitals. Although there is a growing literature addressing the difficulties of EPR implementation – including doctor usage , user reWard rounds are a notable hospital context in which staff work as a group. Technology designed for a single user, like most EPR systems, poses challenges to group interaction – an issue not widely discussed in the healthcare literature. Using theory from the field of human–computer interaction, we evaluate EPR usage through a comparative study of interaction during ward rounds in an intensive care unit (ICU) that transitioned from a paper patient record to an EPR. We highlight the role of physical group formation and the ergonomics of each system in facilitating or hindering group use of patient records.The medical lead of the ICU described in the present paper initiated a switch to an EPR from a paper record in order to improve record keeping such as prescription legibility, adherence to guidelines, and research and development opportunities. Funding was approved in spring 2006 for the purchase of a commercially available clinical information system , which was deployed bed by bed across the unit on 6 November. Between the funding approval and the deployment, an implementation steering group established a plan to introduce the system, overseeing the customization process to meet the needs of the unit as well as examining probable changes, or disruptions, to work practices.The implementation steering group was particularly concerned about how the new system might impact job satisfaction and communication between various medical practitioners. With the agreement of the trust authorities and the Caldicott guardian, the steering group invited a multidisciplinary team of researchers including social and computer scientists to observe and record working practices pre and post change, starting in summer 2006. Their observations were fed back to the implementation steering group on a regular basis to help them ensure a smooth migration from paper patient records to EPRs. The researchers were not funded by the hospital, and decisions to adjust work practices lay entirely with the implementation steering group.As the research does not contain any patient data or interaction, it has been classified as an audit by the Cambridgeshire Research Ethics Committee and therefore does not require ethics approval. All of the medical practitioners observed or interviewed, however, were aware of the purpose of the studies – particularly the consultant videoed (author AV).Our analysis aims to answer the following question: How does interaction during clinical ward rounds vary when an EPR is used in place of a paper record?Given the complex nature of interaction of multidisciplinary communication in an ICU, we have chosen to triangulate three types of qualitative data: video-based interaction analysis, observation, and interviews. Video-based interaction analysis is a technique intended 'to identify regularities in the ways in which participants utilize the resources of the complex social and material world of actors and objects' . It is aThe primary function of ward rounds is to provide an occasion for the medical team to review and integrate information as a group in order to make a clinical decision -10. As tUsing this analytical perspective to support the video analysis, along with the data from observation and interviews, we demonstrate how the ergonomics of the two record types affect group formation. We consequently demonstrate the way in which members of the ward round team use body orientation and posture to negotiate interaction in terms of conversation advancement and entry.Ward rounds were video recorded by author CM, trained in anthropological techniques of field observation and video-based interaction analysis. Video recordings were obtained at three points during the observation period of 13 months: 1 month prior to deployment of the EPR, 4 months after deployment of the EPR, and 1 year after deployment of the EPR. Each time, six separate, randomly selected patient discussions were filmed. To enable comparison, those ward rounds selected for filming were always managed by the same consultant.Images from the video recordings were shared with members of the implementation steering group – including the consultant videoed – 6 months after deployment of the system, and the effects of the introduction of the EPR on group interaction were discussed. Patient privacy was ensured at all times by avoiding capture of images that might allow patient identification.Video footage was complemented by observation during the above three periods both at the time of filming and on another day. Further observation took place the week after deployment and of other consultants throughout the observation period. Three rounds of interviews were conducted at similar time intervals by author MJ. Seven participants were drawn from all medical and nursing roles, including at least one teaching nurse who was responsible for carrying out the training on the system. Effort was made to interview the same people each time, but due to scheduling there were some substitutions.The ICU, consisting of 25 critical care beds, is part of a specialist hospital that concentrates on all aspects of adult cardiothoracic care. Approximately 70% of admissions are patients recovering from cardiac surgery. The unit has a high turnover with a 3-day median duration of stay.There are approximately 200 practitioners working in the ICU, with at least 30 on duty at any one time. These practitioners include a consultant intensivist (senior doctor), two specialist registrars on duty for critical care (junior doctors), one sister in charge of the nurses in the unit (head nurse), one senior nurse in charge of each of three clusters of patient beds, one nurse looking after each of the 25 patients, the intensive care pharmacist, the intensive care dietician, and a team of physiotherapists. The large nature of the unit results in the on-duty group changing configuration regularly.The ward-round team is made up of a member from each of the above roles as appropriate  – consultant, two registrars, head nurse, senior nurse, bed nurse, pharmacist, dietician and head of physiotherapy – comprising eight to 10 people, with possible additional medical students or support from consultants, microbiologists, or surgeons. Although the team structure is consistent, different individuals may fulfil each role on a given day.The multidisciplinary ward-round team travels from bed to bed each morning to review patient progress. The team updates itself on each patient's condition through discussion and chart review, and decides upon the patient's plan for the day. As the round is business orientated, aiming to review all 25 beds in the short period of time ahead of postoperative admissions, little time is devoted to teaching. The daily plan and prescriptions, however, are filled out during the ward round when possible.The ward round begins with one of the registrars presenting the most pertinent details of the patient and any recent changes. The discussion that ensues is led by the consultant working systematically through a number of issues, as appropriate. Any member of the ward-round team can contribute to discussion or may be specifically called on by the consultant for their expertise. The ward round is usually close by the consultant asking 'is there anything else?' Although there is no particular structure for participation by the medical staff, the consultant videoed (author AV) strongly encourages participation from all of those involved in the ward round.The paper patient record, shown in Figure The EPR, provided by Metavision, is a system developed specifically for intensive care use, allowing full integration of data gathered at the bedside into a highly customizable interface. The record includes parameters from ventilators, monitoring devices, laboratory results, prescriptions, and medical and nursing records. A summary screen that displays the most important information about the patient's condition was developed for use during the ward round. All other screens – that is, those giving detailed data on particular aspects of a patient's condition and treatment – are accessible via tabs displayed across the top of the summary screen as shown in Figure A multidisciplinary team at the hospital designed the initial interface to be used in the unit before implementation. The software allows the clinical design team to make changes on the fly and to react to staff feedback, such that the interface is constantly evolving. Consequently, there were no major software issues and, fortunately, no technical difficulties.The EPRs are displayed on 19-inch monitors positioned on an adjustable height trolley at the end of each bed. The trolley can be moved around the bed, but its range is limited because of the wire connections to the ceiling. The screen cannot be rotated, but the trolley itself can. The trolley is generally not moved during the ward round, although the bed nurses frequently adjust the trolley for themselves.Group formation during the multidisciplinary ward round changed considerably during the observation period, as demonstrated in Figures One month prior to deployment of the EPR, with the paper record the consultant took his position at the head of the table, leaning in towards the paper and spreading his hands across it. His body orientation towards the charts suggests them to be the primary focus of the conversation and everyone else orients towards the charts as well.Four months after deployment of the EPR, the consultant's orientation towards the screen displaying the electronic record does little to direct the attention of those who cannot see the screen. The consultant in this case loses his ability to guide the focus of the group and, not surprisingly, the gaze of the medical staff in the outer ring tends to wander.One year after deployment of the EPR, while the consultant remains oriented toward the computer screen, the registrars and medical staff have adjusted to form a horseshoe around the patient's bed. From this position, the ward-round team can easily monitor the consultant's gaze and reactions toward the conversation. The team frequently follow his gaze to the patient and monitor or keep their attention on the faces of those speaking. The consultant leads the conversation, not by focusing the team's attention on the data but on the conversation itself.One month prior to deployment of the EPR, the posture taken by the consultant – as shown in Figure Four months after deployment, when using the EPR, the person with the mouse – typically the consultant – had the same ability to guide the conversation noted previously. He could only, however, direct the focus of those who could see the screen.One year after deployment of the EPR, the upright posture of the consultant and his position, slightly farther back from the computer so that his face could be seen easily, facilitated the ward-round team in following the consultant's focus. It also allowed the consultant to monitor the attention of the ward-round team. A question to one of the medical staff was used twice to refocus that person, providing another tool for the consultant to lead the team.One month prior to deployment of the EPR, within the ward round, side conversations often took place between the nurses or between the pharmacist and another medical staff member. To request such a conversation when using the paper record, a chart was picked up and both parties reoriented themselves to it. In this position, the parties could have a conversation while still visually monitoring the main conversation.Four months after deployment, the EPR offered no means to invite reorientation; neither could the main conversation be monitored visually as the only connection between the rings in the formation was aural.One year after deployment of the EPR, side conversations remained rare and were limited to a sentence or two, with the two parties occasionally shifting closer to one another but not reorienting themselves. Following the completion of the ward round, however, there would be numerous small conversations. As the intensive care pharmacist commented, before the introduction of the EPR she would have reviewed and made changes to drug charts during the ward round, now she focused on the team discussion during the round and made her interventions afterwards.One month prior to deployment of the EPR, posture was a significant indicator of participation in the conversation. Leaning into the circle provided a clear indication of one's desire to speak, and this was usually granted by the consultant reorienting towards that person. Another way of starting the conversation was to place a chart in front of the consultant or registrar, putting the onus on one of them to open the discussion. Direct verbal requests to enter the conversation were either ignored or treated tersely.Four months after deployment of the EPR, the only means available to medical staff to request entry into the conversation was through direct verbal interruption. Not surprisingly, there was a decrease in communication between doctors and nursing staff.One year after deployment of the EPR, there were two ways through which people entered the conversation. Either a member of the team stepped into the horseshoe to gain attention, or the consultant logged out of the EPR, stood back from the computer, and asked whether there was anything else to discuss. This formation allows the consultant to see everyone, and results in a greater likelihood that these requests will be acknowledged. General questions from the consultant to the team also gave medical staff a reason to speak up, with staff often leaning into the formation to answer the question or point to something.The almost circular formation and a less constant orientation towards the data seemed to change the dynamic of the interaction. Medical staff responded to discussions more frequently without necessarily requesting the focus of the group. Their confidence to speak out may also have been bolstered by greater preparation before the ward round – a phenomenon several staff reported as a solution to not being able to see the screen. As with the pharmacist's interventions, therefore, introduction of the EPR meant that certain activities were carried out in series rather than in parallel.Strong multidisciplinary collaboration in an ICU context is known to be beneficial for patient outcomes , but is A number of technical solutions that might ease the blocks to interaction caused by the physical setup were explored. The implementation steering group had discussed sitting ward rounds, in which the EPR is projected onto the wall, but rejected them because they did not include the bed nurse or the patient. Larger screens were considered, but the cost was prohibitive.The computer science researchers investigated handheld devices, or PDAs, as a way of allowing the ward-round team to change their formations. Preliminary results, however, suggest that this is not as helpful as expected . HandhelIronically, the one type of technology that was found to be useful was paper printouts containing basic information for each member of the medical staff, which helped them orient towards the interaction. Although EPRs have many benefits, they often do not make a unit paperless. This is a finding common across sectors .Often there is not a single technical solution to support complex social environments, but rather a need to balance the technology and the social context to enable existing interaction mechanisms. A first indicator that the technological setup is not facilitating interaction is a broken (noncontinuous) formation. When training time is available, we have, in another article, proposed exercises that ward-round teams can do to better understand how their formations around technology affect interaction by constraining formation in unusual ways and then encouraging the team to discuss possible useful changes in the technology or the interaction . In caseThe introduction of an EPR into the ICU of the hospital disrupted the way in which the multidisciplinary team organized itself at the patient's bedside, decreasing both the consultant's ability to lead through directing the focus of the group and the opportunity of medical staff to participate in the conversation. Awareness of these disruptions provided by the observing research team and discussions of formations around two records assisted the ward-round team in adapting their behaviour to promote more effective interaction. This adaptation can be seen by an increase in doctor–nurse interaction during the ward round and a decrease in wandering attention seen 1 year after implementation and 6 months after the researchers' findings were discussed with the implementation steering group.• EPRs are designed for a single user but are frequently used by groups during the ward round.• Group formation, and the resulting nonverbal behaviour that it allows, is an important way of negotiating who speaks and what is spoken about during ward rounds but can be affected by the ergonomics of the technology used.• In the example presented, the head consultant loses his ability to direct the conversation and other medical practitioners have difficulty participating in the ward round when using the EPR.• Prior research into multidisciplinary communication in intensive care suggests that these changes can significantly impact the effectiveness of the interaction.• We suggest the solution may not be entirely technical, but rather a balance between finding the correct technology and adjusting interaction patterns around it, paying particular attention to formation and access to information.EPR: electronic patient record; ICU: intensive care unit.The software developer  and the software UK distributor  have contributed a nonrestricted educational grant to AV's research funds. All other authors declare that they have no competing interests.CM videoed and observed the ward rounds. MJ conducted interviews and analysed the results. AB and AV contributed to the study design. CM, MJ, and AB carried out the video analysis. CM, MJ, and AV drafted the paper.


During embryogenesis in mouse, the thymus is seeded by waves of hematopoietic stem cellsthat provide the first peripheral T lymphocytes after birth. It is known that embryo thymocytesand adult thymocytes have different phenotypic and functional features. The identificationof genes expressed in the thymus only during embryogenesis would help to understandthe molecular basis underlying these characteristics. We used the mRNA differential displaytechnique to compare gene expression between thymus and kidney from embryo (171/2 days)and adult mice. This technique is the method of choice for comparing gene expressionbecause it is able to display rapidly and simultaneously the mRNA complement from severaldifferent types of cells. The major drawback of the method is that it leads to the cloning ofmany false positives and therefore needs a high throughput method to screen for the truly differentiallyexpressed cDNAs. We combined advantages from previously described methodsin order to develop a new version of the mRNA differential display technique that is fast,cheap, and reliable. Instead of oligo dT priming, we used random hexameres for the reversetranscription of total RNA and 10-mer primers for the amplification of internal parts of thecDNAs. We obtained reproducible and clean patterns of discrete bands. We were able to easilyidentify DNAs differentially amplified between embryo and adult tissues , between thymus and kidney , or between embryoand adult thymus  cDNA fragments. After reamplification,cloning, and sequencing of these DNA fragments, it appeared that in most cases, oneband corresponded to a single DNA sequence. On a northern blot, each of these candidategenes recognized a transcript that is differentially expressed as expected. Thus, we report anoptimized, reproducible, and fast mRNA differential display method that overcomes the usualproblems met with the originally described technique or its reported modifications.


Eukaryotic cell cycle progression is controlled by a host of cyclin/cyclin-dependent kinases (Cdks), that are themselves regulated by multiple factors, including a group of small cyclin-Cdk inhibitor proteins . The involvement of Cdk inhibitors in carcinogenesis has been demonstrated by the studies of p16. p53 is frequently mutated in thyroid carcinomas and p21/Waf1 is a downstream effector of p53. It is conceivable that genetic defects of genes downstream in the p53 pathway could also be oncogenic. We, therefore, examined a series of 57 thyroid tumour specimens (eight follicular adenomas and 49 carcinomas) for deletion and point mutation of the p21/Waf1 gene. Three different kinds of deletions ranging from 349 to 450 bp were detected in five papillary carcinoma specimens by reverse transcription-polymerase chain reaction (RT-PCR). All the deletions were involved in the second exon of the p21/Waf1 gene. RT-PCR single strand conformational polymorphism (SSCP) analysis of remaining samples failed to reveal any point mutations in the coding region of the gene, except for a polymorphism at codon 31 (Ser to Arg). Genomic Southern blot analysis did not demonstrate any gene deletion or rearrangement in these samples, indicating abnormal RNA splicing may be involved. Analysis of intron-exon boundary and the coding region of the second exon did not reveal any mutation except for a point mutation (C to G) located 16 bp downstream from the splice donor site of the second intron in three out of five samples with p21/Waf1 deletions. Whether the mutation plays any role in aberrant RNA splicing remains to be determined. Among the five samples with p21/Waf1 gene deletions, none of them simultaneously carried a p53 or retinoblastoma (Rb) gene mutation. No p21/Waf1 abnormality was found in the benign adenomas. Thus, 12.5% (5/40) of thyroid papillary carcinoma specimens harboured p21/Waf1 gene deletions. Our data suggest that p21/Waf1 gene deletion is involved in thyroid carcinogenesis and may play an important role in thyroid cell transformation.


Helping the large number of problem drinkers who will never seek treatment is a challenging issue. Public health initiatives employing educational materials or mass media campaigns have met with mixed success. However, clinical research has developed effective brief interventions to help problem drinkers. This project will employ an intervention that has been validated in clinical settings and then modified into an ultra-brief format suitable for use as a public health intervention. The major objective of this study is to conduct a randomized controlled trial to establish the effectiveness of an ultra-brief, personalized feedback intervention for problem drinkers.Problem drinkers recruited on a baseline population telephone survey conducted in a major metropolitan city in Canada will be randomized to one of three conditions – a personalized feedback pamphlet condition, a control pamphlet condition, or a no intervention control condition. In the week after the baseline survey, households in the two pamphlet conditions will be sent their respective pamphlets. Changes in drinking will be assessed post intervention at three-month and six-month follow-ups. Drinking outcomes will be compared between experimental conditions using Structural Equation Modeling. The primary hypothesis is that problem drinkers from households who receive the personalized feedback pamphlet intervention will display significantly improved drinking outcomes at three and six-month follow-ups as compared to problem drinkers from households in the no intervention control condition. Secondary hypotheses will test the impact of the intervention on help seeking, and explore the mediating or moderating role of perceived drinking norms, perceived alcohol risks and the problem drinker's social reasons for drinking.This trial will provide information on the effectiveness of a pamphlet-based personalized feedback intervention for problem drinkers in a community setting.ClinicalTrials.gov registration #NCT00688584. The ratio of problem drinkers to those seriously dependent on alcohol is about 4:1  has noteIn 1990, the Institute of Medicine ,15. FurtAs problem drinking is one of the five leading contributors to the global burden of disease , there iIs the conclusion that public health educational initiatives cannot directly cause reductions in alcohol consumption a definitive one? We do not believe so. Our argument is that educational initiatives would benefit from looking at the brief intervention literature. As will be outlined below, there is substantial evidence that brief alcohol interventions can have a significant impact on problem drinking ,22. The Personalized alcohol feedback interventions are designed to increase motivation for behavior change ,33. SuchPersonalized alcohol feedback has been found to promote behavior change in drinkers ,35-45. IPersonalized alcohol feedback interventions are particularly well suited for pamphlet-based delivery. This is because such interventions can be translated into a simple, self-test format. The other advantage of personalized feedback interventions is their brevity – both as far as the assessment required and in the time required to complete them. Such features are important as pamphlets sent directly to households have to attract the readers' attention quickly and be easy to complete. Neighbors and colleagues  have alsSeveral researchers have applied self-regulation theory  as a modThe motivational impact of perceived risk is clearly shown by considering four cognitive theories of health protective behavior. In particular, the health belief model , protectWhy might perceived risk mediate the impact of personalized feedback interventions? As was discussed earlier, such interventions provide normative feedback to respondents, comparing their drinking to others in the general population. As many heavy drinkers overestimate how much others drink, this normative information often comes as a surprise to them, allowing them to make the social comparison that they drink more than others . AccordiOne alternative explanation of the role of perceived risk is that it may also act as a modifier of respondents' reactions to safe drinking interventions. That is, problem drinkers may vary in their perceived risk about drinking at baseline, before they receive the intervention. Those problem drinkers who perceive some risk with regard to their drinking may utilize the intervention and reduce their drinking. Those problem drinkers who perceive no risk associated with their drinking may disregard the intervention materials and thus display no reduction in drinking.Using the theoretical underpinnings of expectancy research ,62 and tThere are two previous studies that have employed this same personalized feedback pamphlet.This pilot study demonstrated the potential of the ultra-brief intervention for problem drinkers to be used in the present study . The "Evp < .06). In contrast, among problem drinkers who perceived some risk, respondents who received the pamphlet were drinking less than those who did not (p < .05).The pamphlet was sent by unaddressed ad mail to households, randomized by block to receive or not receive the brief intervention. A random digit dialing telephone survey was conducted in the following month to assess differences in drinking between experimental conditions. The primary result was a 3-way interaction between pamphlet condition, perceived risk, and problem drinking status. The pattern of means indicated that the manner in which perceived risk mediated the impact of pamphlet conditions differed, depending on whether respondents met objective criteria for problem drinking. For non-problem drinkers there was no significant difference between intervention conditions, irrespective of whether the person perceived his or her drinking to be of some or no risk. However, among problem drinkers who perceived no risk, there was a trend for those who received the intervention to drink more as compared to those who did not receive the intervention . Notably, we observed no iatrogenic effects of providing the pamphlet to drinkers who did not meet criteria for hazardous drinking at baseline, i.e., no escalation of drinking among no-problem drinkers after receiving the ultra-brief intervention.Wild and colleagues conducted a trial that further supported the ultra-brief pamphlet intervention . DrinkerAlthough the results of this study are encouraging, only respondents who were interested in receiving self-help materials were recruited for the intervention. For the present study, we intend to evaluate the impact of the ultra-brief pamphlet intervention, whether the respondent is specifically interested in receiving self-help materials or not (note: while still maintaining fully informed consent). This is a challenging undertaking but we feel that such a goal is essential if we are to evaluate the effectiveness of the intervention within the same setting that interventions, such as the one to be used in the present study, would be employed in real life. It should also be noted that only recruiting respondents who say they are interested in self-help materials has the additional limitation of excluding many respondents who perceive no risk associated with their drinking. In Preliminary Study # 1, 76% of the respondents who perceived no risk associated with their drinking also said they were not interested in self-help materials. Thus, we must employ a design that recruits all problem drinking respondents, whether interested in self-help materials or not, in order to fully explore the public health impact of this intervention approach, and to conduct an adequate test of the potential role of perceived vulnerability as a mediator and a moderator of the intervention effects. One final limitation of the Wild et al. study was that there is no way to tell whether the observed impact on drinking was due to the content of the personalized feedback pamphlet or simply because the respondent received any alcohol-related pamphlet at all. Thus, the current study incorporates a second control condition in which the households of a randomized third of the participants will receive a popular educational pamphlet on alcohol that contains no personalized feedback content.The principal research objective is to evaluate the efficacy of a pamphlet-based self-help intervention among problem drinkers in the general population. The development of an effective, research-based pamphlet of this type is important because of its potential for use in public health initiatives where low-cost and wide distribution are key considerations. In order to mimic the use of a personalized feedback pamphlet in a public health initiative, the pamphlet will be sent unaddressed to households rather than to specific individuals. In addition, because it is important to determine whether it is the content of the personalized feedback pamphlet or just the receipt of any pamphlet that leads to reductions in drinking, a control pamphlet condition will be included in the study.The proposed research will evaluate the efficacy of a pamphlet-based personalized feedback intervention for problem drinkers in the general population.The hypotheses regarding the efficacy of the pamphlet-based intervention are:Hypothesis 1: Respondents from households who receive the personalized feedback pamphlet-based intervention will display significantly improved drinking outcomes at three and six-month follow-ups as compared to respondents from households in the no intervention control condition.Hypothesis 2: Respondents from households who receive the personalized feedback pamphlet-based intervention will display significantly improved drinking outcomes as compared to respondents from households who receive the control pamphlet.In addition, two mediator hypotheses will be tested:Hypothesis 3: Respondents who receive the intervention and reduce their estimates about how much others drink between baseline and three-month follow-up will display significantly improved drinking outcomes at six-month follow-up as compared to respondents who receive the intervention but experience no decrease in their perceived drinking norms.Hypothesis 4: Respondents who receive the intervention and experience an increase in their perceived vulnerability to experience harm because of their alcohol consumption between baseline and three-month follow-up will display significantly improved drinking outcomes at six-month follow-up as compared to respondents who receive the intervention but experience no increase in their perceived risk.Finally, two moderator hypotheses will be tested:Hypothesis 5: The impact of the intervention will be greater among drinkers who believe that they are personally vulnerable to negative outcomes at baseline assessment, compared to drinkers who do not believe that they are personally 'at risk' before receiving the intervention.Hypothesis 6: Respondents who drink for social reasons will be more likely to reduce their drinking as a result of the intervention as compared to respondents who do not drink for social reasons.In an initial telephone interview, sociodemographic information will be collected. Current drinkers will complete a standardized epidemiological assessment of problem drinking and alcohol consumption, and will answer items to assess their perceived drinking norms, their perceived risk regarding drinking and their social reasons for drinking. Respondents identified as problem drinkers will be asked if they are willing to participate in a three-month and a six-month follow-up. Respondents will be offered a $20 honorarium for completion of each of the three-month and six-month follow-ups. Verbal informed consent will be gathered and respondents will be told that some households will be receiving a pamphlet. Problem drinking will be defined as a score of eight or more on the Alcohol Use Disorders Identification Test (AUDIT) ,65. The Why do we believe that the proposed study design is the best for testing the impact of this personalized feedback pamphlet? The intent of this project is to evaluate an ultra-brief intervention for problem drinkers that can be used in public health initiatives. As such, it is important that the intervention pamphlet be evaluated in a setting that mimics how it will be used. Thus, the pamphlets will be sent addressed to the household rather than addressed to the respondents because public health initiatives are often non-specific in their target recipients. The proposed research design has the advantage of allowing the pamphlet to be sent to all households in the intervention condition, irrespective of whether any of the respondents are specifically interested in receiving self-help materials. In order to conduct a study where intervention materials are sent directly to the person by name, for ethical reasons the respondent must at least state that he or she is hypothetically interested in receiving such materials. A study in which materials are sent unsolicited to households has been judged ethical because receiving such materials unsolicited  is not an unusual occurrence given that public health initiatives are ongoing in the Toronto metropolitan area. However, informed consent is given because all respondents are told about the possibility of their household receiving the pamphlet. Further, it is important to be able to send materials to all households because interest in self-help materials covaries with respondents' perceived risk. In the pilot study described above, 76% of problem drinkers who perceived no risk associated with their drinking were not interested in self-help materials. This group comprised 32% of all problem drinkers in the sample. Thus, although the proposed method reduces the power of the intervention because not all respondents will see the pamphlet, it is still the best design for our purposes because it allows recruiting some problem drinkers with no perceived risk regarding their alcohol consumption. Studying the reactions of problem drinkers who do not perceive any risk associated with their drinking to intervention materials is of great importance because results from the pilot study for this proposal (Study 1 in the preliminary studies section) indicated that this group could react to the intervention materials by drinking more. Although the results of Study 1 were not conclusive because of its post-test only design and the fact that this 'boomerang' effect in reaction to the materials was a trend rather than a statistically significant result, we feel that the study of these types of unintentional effects is essential. The personalized feedback pamphlet is intended for wide distribution in the general public. If we confirm that this ultra-brief intervention can have a negative impact on some sub-groups of problem drinkers then this finding would speak to the need to target the intervention to only those drinkers who already voice some concern regarding their drinking. As there is insufficient evidence to-date that could confirm or refute this hypothesis, we feel that the need to test this hypothesis appropriately outweighs the potential ethical dilemma of causing a small unintended increase in alcohol consumption among a population of drinkers who are not seeking treatment and who meet criteria for a rather liberal definition of problem drinking (AUDIT score of 8 or more).The study was approved by the standing ethics review committee of the Centre for Addiction and Mental Health. Telephone calls will be made by trained interviewers from the Institute of Social Research at York University (Toronto). The interviewers will introduce themselves, indicate they are calling from York University and that they are calling on behalf of the Centre for Addiction and Mental Health, which is conducting research on drinking. They will determine the number of monthly drinking adults in the household, randomly select one of them (according to most recent birthday) and before they start the interview they will read the following script:"I would like to assure you that all information you provide, including your answers, identity, and any other information will remain completely confidential. You do not have to answer any questions you do not want to and if you decide to stop the interview, and wish us to do so, we will destroy all the information you have given us. On average, the interview will take about 15 minutes. Just to let you know, from time to time my supervisor may listen in to make sure we are doing the research correctly. The survey is voluntary, but your participation is very important if the results are to be accurate. Is now a good time to start the interview?"At the end of the baseline survey, all problem drinkers (AUDIT ≥ 8) will be asked to participate in two, 15 minute surveys, the first in about three months time and the second in six months time. Participants will be offered $20 for the completion of each of the three-month and six-month follow-ups. Potential respondents will be told that these surveys will ask about their current drinking. Further, they will be informed that "the Centre for Addiction and Mental Health is in the process of mailing a safe-drinking pamphlet to some households in Toronto. I do not know if this pamphlet is being sent to your household, but if you do see it, the six-month follow-up survey will ask about your impressions of the materials." Respondents who agree to the follow-up will provide their name, address and telephone number. Because the baseline interview contact is made by telephone, verbal agreement to participate in the study will act as providing informed consent. Respondents will also be informed of the request to provide a collateral on the six-month follow-up at this time.The "Evaluate Your Drinking" self-test pamphlet was modeled after the Drinker's Check-up ,40,66 anThe control pamphlet called 'Do you know .... Alcohol' is disseminated by the Centre for Addiction and Mental Health (CAMH). This pamphlet provides good quality information about alcohol, consequences of its misuse and safe drinking guidelines . The "Do you know" pamphlet is one of the most popular distributed by CAMH and is a high quality pamphlet that is a good example of educational materials disseminated about alcohol [see Additional file (1) The Alcohol Use Disorders Identification Test will be used to measure level of alcohol consumption and severity of alcohol problems  ,65. The (2) Six items assessing whether in the past 12 months alcohol had a harmful effect on respondents' (1) friendships/social life, (2) physical health, (3) outlook on life (happiness), (4) home life or marriage, (5) work, studies, or employment opportunities, or (6) financial position .(3) Perceived drinking norms will be measured using a modified version of the Drinking Norms Rating Form . Respond(4) Perceived risk for drinking-related problems will be assessed using a six-item scale with questions about perceived vulnerability to harm from the drinkers' own perspectives .(5) Following the procedure used by Neighbors , social (6) Formal addictions treatment utilization will be measured using a single item from the National Longitudinal Alcohol Epidemiological Survey ; "Have y(7) A series of demographic characteristics will be assessed: age, gender, ethnicity, marital status, education, and employment status.Problem drinkers (AUDIT score of 8 or more) will be recruited to participate in a three-month and a six-month follow-up telephone survey.The three-month follow-up will occur roughly three-months after the intervention pamphlet is sent .(1) Drinking in the last three months will be assessed using the same five items employed on the baseline survey, the first four framed for the past three months  and the last asking how much the person drank on each day of the last week.(2) Six items assessing whether in the past 3 months alcohol had a harmful effect on respondents' (1) friendships/social life, (2) physical health, (3) outlook on life (happiness), (4) home life or marriage, (5) work, studies, or employment opportunities, or (6) financial position .(3) Mediator variables, perceived drinking norms and perceived risk will be measured using the same items as on the baseline survey.(4) Formal addictions treatment utilization will be measured using the same single item as the baseline survey, modified to ask about the last three months.(1) Using the same measures of alcohol consumption as the baseline survey, respondents' drinking over the time since the three-month follow-up will be assessed.(2) The same six items assessing any harmful effects of alcohol in the past 3 months alcohol.(3) Formal addictions treatment utilization will be measured using the same single item as the baseline survey, modified to ask about the last three months. In addition, respondents in the personalized feedback pamphlet condition will be asked if they called the telephone number provided on the pamphlet in order to assess whether the pamphlet stimulates additional help seeking.(4) Knowledge of whether the household received any drinking-related materials will be assessed. Respondents will be asked if their household received either of the two pamphlets that were mailed. If they received one they will be asked which one and whether they read it. Those who received the "Evaluate Your Drinking" pamphlet and read it will be asked if the did the self-test contained in the pamphlet.At the six-month follow-up respondents will be asked to provide the name of a collateral to confirm their drinking self-reports. Collaterals identified for participation will be mailed a letter explaining that they have been nominated to act as a collateral. Collaterals will then be contacted by telephone to confirm their willingness to talk about the respondent's drinking. The 10-minute telephone interview will cover the respondent's drinking in the past three months and any use of treatment services for alcohol problems during the past three months (mirror items of the respondents' six-month follow-up survey). Collaterals will be offered a $20 honorarium for completing this interview.The power analysis conducted to estimate the sample size required to test the hypotheses of this study used the procedures suggested by Cohen  for estiAlthough Structural Equation Modeling , the anaThe analysis plan will follow the description of the use of Structural Equation Modeling (SEM)  for the The primary goal of this project is to evaluate the efficacy of an ultra-brief self-help intervention for non-treatment seeking problem drinkers in the general population. One strength of the proposed study is that it merges population-based methods with a randomized controlled trial. Thus, a general population survey will be employed using a random digit dialing method in order to recruit a good cross-section of problem drinkers from the Toronto population. Respondents will be randomly assigned to condition, allowing for causal inference about any differences observed.The information from the proposed trial may help illuminate effective ways of promoting change among problem drinkers who do not seek formal treatment. If the project finds support for the efficacy of a pamphlet-based feedback intervention, it would provide justification to substantially increase the accessibility of this self-help method for problem drinking. This would be accomplished by sending the pamphlet directly to the public in bulk mailing, to health care settings , and to other social services such as unemployment agencies and welfare departments. As problem drinking is common in all these settings, a research evaluated ultra-brief intervention made freely available to all those in need would help broaden the base of treatment for alcohol problems.AUDIT: Alcohol Use Disorders Identification Test; CAMH: Centre for Addiction and Mental Health; SEM: Structural Equation Modeling.The authors declare that they have no competing interests.All authors have made an intellectual contribution to this research protocol. JAC is the Principal Investigator of the project and wrote-up the protocol. All authors have contributed to the drafting process, and all authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:An electronic copy of the intervention pamphlet, Evaluate Your Drinking, to be used in the research trial.Click here for fileAn electronic copy of the control condition pamphlet, Do you know .... Alcohol, to be used in the research trial.Click here for file


The development of brief, easily accessible ways to help problem drinkers who are unwilling or unable to seek traditional treatment services could therefore have significant public health benefit. The objective of this project is to conduct a randomized controlled evaluation of the internet-based Check Your Drinking (CYD) screener (n = 185) recruited through a general telephone population survey were assigned randomly to receive access to the CYD, or to a no-intervention control group.Participants (Follow-up rates were excellent (92%). Problem drinkers provided access to the CYD displayed a six to seven drinks reduction in their weekly alcohol consumption  at both the 3- and 6-month follow-ups compared to a one drink per week reduction among control group respondents.The CYD is one of a growing number of internet-based interventions with research evidence supporting its efficacy to reduce alcohol consumption. The internet could increase the range of help-seeking options available because it takes treatment to the problem drinker rather than making the problem drinker come to treatment. Problem drinking is one of the three leading contributors to preventable death  and incrWhat other means of helping problem drinkers exist? An ideal option would involve delivery of alcohol interventions so that they could be accessed freely, 24 hours a day, in the comfort of the person's home and free of geographic restrictions regarding treatment availability. If such an option were available, problem drinkers could access it on their own initiative or upon their physician's recommendation. New technologies may make such interventions possible. Primarily, the internet is becoming a common feature of everyday life, and within the next decade will probably be used as widely as the telephone or television . AlreadyIBIs for problem drinkers have been in existence for more than a decade . The majThere are several challenging aspects to consider in evaluating an IBI—the population, the setting and the internal validity of the research trial . The tarn = 397) provided their name, address and telephone number. They were then sent a cover letter and consent form explaining the study, along with a supplementary baseline questionnaire. Those respondents agreeing to participate  signed and returned a copy of the consent form along with the baseline questionnaire . Respondents were then randomized into one of two conditions: (i) an internet personalized alcohol feedback condition (intervention condition); or (ii) a no-intervention control condition. Randomization was conducted using a random numbers list (odd numbers for condition one and even numbers for condition two) with no stratification. All respondents were followed-up in 3 and 6 months' time to determine changes in drinking status . The conduct of this study was approved by the standing ethics review committee of the Centre for Addiction and Mental Health.Recruitment for this study took advantage of an ongoing general population telephone survey that collected socio-demographic and drinking baseline data from a large, randomly selected probability sample of Ontario adults. Drinkers who met minimal criteria for risky alcohol consumption [score of 4 or more on the 3 consumption items from the Alcohol use Disorders Identification Test (AUDIT-C)] were ideA letter was sent to respondents in the intervention condition thanking them for agreeing to participate in the study and containing the internet address (URL) for the CYD and a password to allow access. Respondents were asked to review the CYD and were informed that they would be asked their impressions of the CYD on the 3-month follow-up. If respondents had not accessed the website within a month of receiving the initial invitation letter, they were sent a reminder letter asking them to log on.http://www.CheckYourDrinking.net).The materials employed for the CYD have been modelled after the Drinker's Check-up –33 and tRespondents in the control group did not receive any feedback materials. Instead they were sent a list of the informational components that could be included in a computerized summary for drinkers . A letter accompanied this list thanking them for agreeing to participate in the study, asking them to consider how useful they might find the different components that could be included in a computerized summary for drinkers, and telling them that they would be asked for their opinions on the 3-month follow-up. The listed components were the same as those included in the CYD intervention (e.g. a chart that compares the user's drinking to other Canadians of the same age and sex).Demographic characteristics including age, sex, marital status, education, gross family income and employment status were collected on the initial random digit dialling telephone survey . All other items were collected on the paper survey mailed out with the consent form. These items included the AUDIT ,37. RespBefore conducting the outcome analyses, drinking data at baseline, 3-month and 6-month follow-up were examined for their distributional characteristics. Missing data were replaced with the corresponding baseline data . Drinking variables were also trimmed by replacing any outliers beyond three standard deviations with the next highest value . Two composite outcome measures were chosen that incorporated most of the essential components as outcome measures for a brief intervention. The primary outcome measure was number of drinks in a typical week  ,39. The P > 0.05) effects of sex of the respondent in these analyses, they are not presented here. Finally, we chose a conservative intent-to-treat analysis in which respondents in the intervention condition were included in the analysis even if they never accessed the CYD intervention (35 of 92 possible participants did not access the website).Analyses were conducted using 2 × 2 × 3 repeated-measures analyses of variance (ANOVAs). The within-subjects variable was time of follow-up . Intervention condition (received internet address or control group) and baseline problem drinking status (problem drinkers: score on the full AUDIT of 11 or more versus low-risk drinkers: AUDIT score of 4–10) were the between-subjects variables. Baseline problem drinking status was included in the analyses because previous research employing the CYD has found that this intervention only had an impact with problem drinkers –27. A scP < 0.05 level of significance. However, we were able to include only the three AUDIT-C items in the telephone recruitment survey, as the telephone survey was being conducted for another purpose. Therefore, the senior author of this paper decided to try to recruit as many potential participants as possible using a minimal indicator of risky drinking, i.e. an AUDIT-C score of 4 or more. This decision appears merited in retrospect, as many potential participants who voiced an interest in the study never returned their consent form  = 33.6, P < 0.001 and χ2 = 47.9, 4 df, P < 0.001). Finally, for the 185 respondents enrolled in the trial, attrition analyses were conducted comparing those with complete follow-up data (n = 170) to those with at least partial missing follow-up data (n = 15). There were no significant differences (P > 0.05) in demographic or drinking characteristics between these groups .For the 2746 respondents who met minimal criteria for risky drinking (i.e. an AUDIT-C score of 4 or more), attrition analyses were conducted to compare the characteristics of potential respondents who screened out at each phase of the telephone recruitment survey see . In geneP > 0.05; see Bivariate comparisons were conducted to compare demographic and drinking characteristics between the experimental and the control conditions at baseline . None of these comparisons were significantly different  = 13.8, P < 0.001, partial eta squared = 0.13), which was qualified by a significant time × intervention interaction  = 7.5, P = 0.001, partial eta squared = 0.077), and a significant time × baseline problem drinking status interaction  = 9.7, P < 0.001, partial eta squared = 0.098). These two-way interactions were qualified further by a significant time × intervention × baseline problem drinking status interaction  = 7.9, P = 0.001, partial eta squared = 0.081). Post-hoc analyses revealed that, for problem drinkers, there was a significant reduction in typical weekly drinking (P < 0.05) from baseline to 3-month follow-up (average of seven drinks per week reduction) and from baseline to 6-month follow-up (average of six drinks per week reduction) for respondents who were in the intervention condition, but no significant reduction (P > 0.05) in drinking from baseline to either time-point for respondents in the control condition (average of one drink per week reduction). Low-risk drinkers did not reveal a significant reduction (P > 0.05) in their drinking in either the intervention or the control conditions.Means for typical weekly drinking and AUDIT-C scores at baseline, 3 and 6 months by intervention condition and problem drinking status are displayed in F = 8.7, P < 0.001, partial eta squared = 0.088) and significant interaction effects for time × intervention  = 5.8, P = 0.004, partial eta squared = 0.06), time × problem drinking status  = 4.5, P = 0.013, partial eta squared = 0.047) and time × intervention × problem drinking status  = 5.8, P = 0.004, partial eta squared = 0.060). As with typical weekly drinking, post-hoc analyses revealed that, for problem drinkers, there was a significant reduction in AUDIT-C scores (P < 0.05) from baseline to 3-month follow-up and from baseline to 6-month follow-up for respondents who were in the intervention condition, but no significant reduction (P > 0.05) in AUDIT-C scores from baseline to either time-point for respondents in the control condition. Low-risk drinkers did not reveal a significant reduction (P > 0.05) in their AUDIT-C scores in either the intervention or the control conditions.A separate 2 × 2 × 3 repeated-measures ANOVA compared AUDIT-C scores at baseline, 3-month and 6-month follow-ups between intervention condition (received URL for CYD website versus control condition) and problem drinking status at baseline. There was a main effect of time . Respondents were then assigned randomly to condition, allowing for causal inference about any differences observed. Results from the trial are promising, with problem drinkers who were provided access to the CYD displaying a six to seven drinks per week reduction in drinking compared to controls . The size of this reduction is of the same magnitude as has been observed in face-to-face brief interventions for problem drinking in primary health care settings .The primary limitation of this study is that about one-third of those in the intervention condition never accessed the CYD. Thus, with its conservative intent-to-treat analysis , this trial is a comparison between those provided access to the CYD versus those who were not. The fact that many people did not access the CYD intervention (despite having said they would be interested in such a service on the baseline telephone survey) emphasizes the point that providing access to IBIs, or any other intervention, does not guarantee that problem drinkers will use them. Indeed, no one intervention is an ideal solution and a sensible option for promoting access to care is to increase the variety of research-based interventions available so that problem drinkers can choose one  that is suitable to them.Other limitations of this study include the large number of potential participants who could have agreed to take part in the research but chose not to. This loss of potential participants could, in part, reflect that the current study did not recruit problem drinkers seeking help but rather proactively recruited from the general population . In addiNevertheless, we are encouraged by the results of this trial given the methodological rigor of this research. Mainly, the study demonstrated the possibility of attaining an excellent follow-up rate, something that is rare in evaluations of internet-based interventions in a general population context . We spec