White-nose syndrome is a fungal disease that has killed millions of hibernating bats. One symptom is electrolyte depletion. We tested whether providing an electrolyte supplement, a potentially simple and cost-effective conservation intervention, to hibernating bats would reduce disease severity. The treatment was not effective and may have increased fungal growth. Myotis lucifugus) to test whether providing supplemental energy and electrolytes  to hibernating bats could reduce severity of WNS symptoms and increase survival. Infected bats in the Pedialyte-supplemented group generally avoided the Pedialyte and preferentially drank plain water. We did not observe any differences in survival, arousal frequency or blood chemistry, but bats in the Pedialyte-supplemented group had higher fungal load and more UV fluorescence than the control group that was only provided with water. Supplemental electrolytes would be an attractive management strategy because of their low cost and logistic feasibility but our results suggest this approach would be ineffective. However, it could be useful to conduct preference experiments with multiple dilutions and/or flavours of electrolyte solution. Although they did not prefer Pedialyte in our experiment, bats in the hand readily drink it and electrolyte supplementation remains an important tool for rehabilitation of captive bats recovering from WNS and other causes of dehydration.Fungi are increasingly recognised as harmful pathogens of wildlife. White-nose syndrome (WNS) is a fungal disease that has killed millions of hibernating bats in North America. High mortality has driven research to identify management strategies for the disease. Increased energy expenditure and fat depletion, as well as fluid loss, hypotonic dehydration and electrolyte depletion appear to be key aspects of WNS pathophysiology. Bats with WNS spend energy too quickly and also lose fluids containing water and electrolytes from lesions on exposed skin surfaces. During periodic arousals, bats often drink water but, in most of the WNS-affected area, food is not available during winter and, therefore, they cannot maintain energy balance or replace lost electrolytes. Therefore, providing a liquid caloric/electrolyte/nutrient supplement could be useful for treating WNS. We studied captive, hibernating little brown bats ( Batrachochytrium dendrobatidis, which causes chytridiomycosis and has led to declining amphibian populations worldwide  and has killed millions of hibernating bats in North America over the past decade. Changes in the relative abundance of bats on the landscape were observed soon after the discovery of WNS , prompting concerns of population-level impacts for many species  from a site north of Grand Rapids, Manitoba, Canada (53.4°N 99.5°W). At the time of collection, this site was >1000 km from the nearest known site with WNS, and all bats were confirmed negative for P. destructans by quantitative PCR  at 15-min intervals throughout hibernation, and the unique markings allowed us to visually identify individual bats in near-IR video recordings  built into a single temperature and humidity-controlled incubator  set to 7°C and 98% relative humidity (0.9818 kPa). We confirmed chamber conditions with temperature and humidity sensors  which recorded conditions every 10 min. We monitored hibernating bats with motion-activated near-IR cameras  that were placed above each cage, ensuring an unobstructed view of all bats within each cage. We reviewed video recordings daily to monitor arousals and to identify individuals which met criteria for humane intervention. Any bats exhibiting signs of morbidity  were removed for assessment with as little disturbance to remaining bats as possible. Any bats that were unresponsive during assessments were humanely euthanized under isoflurane anaesthesia, otherwise were returned to their cage to continue hibernating.Our experiment consisted of three treatment groups: electrolyte supplementation, dextrose supplementation and water control. We provided supplemental electrolytes with a 1:1 dilution of unflavoured Pedialyte  . At thisWithin the first week of captive hibernation, there was an unavoidable repair that had to be made to one of the cages, which we completed as quickly and quietly as possible. After this disturbance, bats were left to hibernate undisturbed and we monitored their condition based on video recordings. After 112 (water treatment) or 113 days of hibernation , we terminated the experiment. All bats were humanely euthanized under isoflurane anaesthesia. We recorded body mass, collected swabs for qPCR analysis of fungal load, and took wing photos under UV light to quantify the amount of UV fluorescence associated with WNS see . BrieflyWe used video recordings to document drinking behaviour in each treatment Fig. . From JaWe compared survival among groups using a Breslow–Gehan survival analysis. Differences in blood chemistry, fungal load and UV fluorescence among groups were assessed using ANOVA with Tukey post hoc tests to identify pairwise differences. We assessed drinking preferences by using binomial tests including all putative drinking events to determine whether bats preferentially drank from one of the two dishes provided in each treatment, and also conducted a binomial generalized linear model (GLM) to compare drinking choices among treatments, accounting for the repeated measurements of individuals. Finally, we compared arousal frequencies with a linear mixed model, testing for treatment differences in the duration of torpor bouts, accounting for date and including individual as a random effect to account for repeated measures. We included only the final 50 days of hibernation in the analysis of torpor bout duration because arousal frequency only increases in late hibernation for bats with WNS. All statistical analysis was completed in R v3.4.2; .P. destructans infection at the time of capture. Body mass at capture was 9.9 ± 0.1g, and did not differ among treatment groups . One bat in the water control group hibernated <50 days and was therefore excluded from our analysis, as this mortality was unlikely to be related to fungal infection. In some cases, cartridges were not available for the blood analyser, or bats died before it was possible to remove them for euthanasia, resulting in smaller sample sizes for blood chemistry analysis for water (n = 15), Pedialyte (n = 9) and dextrose (n = 14). Similarly, final body mass was only reliable for bats that were euthanized because there was no postmortem dehydration, resulting in sample sizes for the three experimental groups of 15, 11 and 14 for mass change throughout hibernation. Sample sizes for fluorescence were 16, 15 and 17, and for fungal load sample sizes were 17, 18 and 16. Finally, iButtons can fail after modification  with more drinking events in the Pedialyte treatment compared with the water group (Tukey post hoc P = 0.003). Individual drinking preference was highly variable and, accounting for repeated measurements of drinking choices among individuals, the effect of treatment approached significance  driven by an apparent preference for water in the Pedialyte treatment. With relatively few drinking events observed for many individuals, the binomial GLM may not have the power to detect drinking preferences for those individuals. Therefore, we also considered overall comparisons of drinking behaviour in each treatment, ignoring the effect of individuals. There was no preference for drinking dish in either the water (P = 0.85) or dextrose (P = 0.81) control treatments, but there was a preference for water over Pedialyte with bats drinking from the Pedialyte dish roughly half as often as from the water dish (P < 0.0001).We observed 477 putative drinking events. In the water control group, there were 54 drinking events at the front dish and 51 at the back dish. In the dextrose group, bats drank from the dish of dextrose 79 times compared with 75 drinking events at the water dish. In the Pedialyte treatment, there were 72 drinking events from the Pedialyte dish compared with 146 at the water dish. The total number of drinking events per individual varied among treatments  and body mass declined to 7.7 ± 0.1g by the end of the experiment. Similarly, there was no difference in survival among the three treatments . The duration of torpor bouts decreased over the final 50 days of hibernation , but there were no differences among treatment groups . Bats in the Pedialyte treatment tended to have shorter torpor bouts than bats in the water control group (LS means contrast P = 0.055), but no other pairwise differences approached significance (P > 0.19). Bats in the Pedialyte group had more UV fluorescence (loge + 1 transformed) than bats in the water control group  but there were no other pairwise differences among treatments . Similarly, fungal load varied among treatments , with bats in the Pedialyte treatment having higher fungal load than bats in the water (Tukey’s post hoc P = 0.001) or the dextrose treatment (Tukey’s post hoc P = 0.046). There was no difference between the fungal load of bats in the water or dextrose treatments (Tukey’s post hoc P = 0.37) . Values for the Pedialyte treatment were less than for the water controls (Tukey post hoc tests P < 0.03), with no other pairwise differences. No other blood chemistry patterns, including sodium and chloride (P. destructans thereby increasing disease severity in that group.A simple prediction for our experiment was that the electrolyte depletion observed in WNS c,d. LoweRegardless of the explanation for increased disease severity in the Pedialyte-supplemented treatment, the unfortunate conclusion of our study is that liquid nutrient/electrolyte supplementation is unlikely to be effective for mitigating effects of WNS in wild bats. Simply put, bats did not voluntarily drink dilute Pedialyte, preferring instead plain water. However, dilute Pedialyte remains a useful option for rehabilitation and recovery of bats, in the hand, affected by WNS or suffering dehydration from other causes. We have used a 1:1 dilution of unflavoured Pedialyte, among other interventions, when treating bats recovering from WNS and other researchers have reported good results from use of Pedialyte for rehabilitating bats suffering dehydration . Bats in


Literature suggests that there is a correlation between video otoscopy and standard tympanometry findings. However, there is limited evidence on whether these two measures are comparable in the identification of middle ear pathologies in adults living with human immunodeficiency virus (HIV).This study aimed to determine the correlation between video otoscopy and standard tympanometry with 226 Hz probe tone in the identification of middle ear pathologies in adults living with HIV in Limpopo, South Africa.A prospective, non-experimental, comparative design was employed on HIV-positive adults aged 18 years and older. All participants underwent basic audiological assessment including case history interviews, video otoscopy, tympanometry with a 226 Hz probe tone and pure tone audiometry. Two ear, nose and throat (ENT) specialists independently analysed video otoscopic images and provided their reports to the researcher, and these were compared to the tympanometry results. The IBM SPSS v.24 was used for data analysis, including the use of Cohen’s kappa to determine the agreement between the two procedures. Pearson’s correlation coefficient was used to determine the strength of the correlation between tympanometry and video otoscopy.N = 161 ears) took part in the study. Middle ear pathology was observed in 8% (n = 13) of the sample when tympanometry was used, and this increased to 10.6% (n = 17) when video otoscopy was utilised. Kappa statistics found a good agreement (k = 0.7) between the diagnoses made by two ENTs. However, there was poor agreement (k = 0.2) between the diagnoses by video otoscopy and tympanometry. Pearson’s correlation coefficient indicated weak correlation between video otoscopy and tympanometry (r = 0.195).A total of 87 adults (Findings from this study suggest that video otoscopy may be more accurate in the identification of middle ear pathologies in adults living with HIV when compared to tympanometry. These findings have training implications in the use of video otoscopy to ensure accuracy and reliability. Clinical implications of current findings include the use of both video otoscopy and tympanometry in a complementary manner for more sensitive identification of middle ear pathologies in this population. Lastly, tele-audiologic implications of the use of video otoscopy to increase access in resource-constrained contexts are raised. The number of people living with human immunodeficiency virus (HIV) continues to increase, especially in sub-Saharan African countries (Joint United Nations Programme on HIV and/or Acquired immunodeficiency syndrome (AIDS) [UNAIDS], Middle ear pathologies often manifest themselves on the tympanic membrane  emphasises the prevention of the impact of middle ear pathologies through early and accurate identification of these pathologies WHO, . TympanoVideo otoscopy holds promise as an alternative measure of middle ear function. Video otoscopy is based on the notion that middle ear pathologies can be diagnosed by analysing the colour and structural changes of the tympanic membrane  in Elias Motsoaledi Local Municipality (EMLM), Sekhukhune district, Limpopo province, South Africa. The EMLM comprises a number of rural villages with an estimated population of 249 363. The prevalence of HIV in Sekhukhune district is reported to be 17.1%   version 24 was used to analyse the data. Descriptive statistics including frequency calculations and percentages were used to summarise the results and describe the characteristics of the sample  and with the Declaration of Helsinki, 2013. The study adhered to the ethical principles outlined in the Declaration of Helsinki  adults diagnosed with HIV. The sample, as depicted in The occurrences of middle ear pathologies in this study were based on the agreement of the diagnoses of the total sample (161 ears). Video otoscopy indicated an occurrence of middle ear pathologies in 11.5% of the sample, with the rest presenting with normal middle ear function. However, tympanometry revealed an occurrence of middle ear pathologies in 8% of the sample, as depicted in n = 5), retracted tympanic membrane (n = 4), tympanic membrane perforations (n = 3), chronic suppurative otitis media (n = 2), tympanosclerosis (n = 1), tympanic membrane scarring (n = 1) and otitis externa (n = 1).The types of middle ear pathologies found included otitis media with effusion (k = 0.7) revealed a substantial agreement between the diagnoses made by the two ENT specialists using video otoscopic images. The 12 ears that ENTs could not agree on their diagnoses were not included when comparing the video otoscopy and tympanometry. Therefore, a total of 161 ears were used to compare the two measures.The video otoscopic findings and the standard tympanometry findings were compared. Of the 173 ears, the two ENT specialists did not agree on the diagnoses of 12 ears (16%). Cohen’s kappa (k = 0.2) indicated poor agreement between the two measures. Of the middle ear pathologies identified by both measures, the two measures only agreed on four diagnoses. A Pearson’s correlation analysis revealed a weak correlation of 0.19  between the two measures.When comparing the diagnoses made through the video otoscopy and tympanometry, Cohen’s kappa  than tympanometry . The occurrence of middle ear pathologies in this study is consistent with published literature indicating that middle ear pathologies are common in individuals living with HIV . Video otoscopy yielded a higher occurrence of middle ear pathologies  than tympanometry with 226 Hz . The higher occurrence obtained through video otoscopy suggests that middle ear pathologies may affect the structures and colour of the tympanic membrane before (or without) affecting its mobility (Hunter et al., Although Ting et al.  reportedCurrent findings suggest that tympanometry alone cannot provide accurate information about middle ear functioning in adults living with HIV, particularly if mobility disorder is not a key or initial feature of the middle ear pathology. These findings seem to suggest that audiologists and other hearing health professionals need to use measures that provide sufficient information about the characteristics of the tympanic membrane, which include structure, colour and mobility in order to achieve the goal of early identification of middle ear pathologies in this population. Although pneumatic otoscopy provides such sensitivity and specificity in terms of middle ear assessment (Ponka & Baddar, Current findings have important clinical implications. Good prognosis has been documented where middle ear pathologies are identified and treated early. Consequences of untreated middle ear pathologies are significant for both patient and the State, and this has been reported by Phanguphangu . It is eAlthough the findings of this study are significant for assessment and management of middle ear function of individuals living with HIV, the results should be interpreted with caution because of the identified methodological limitations. These limitations include the small sample size and the fact that participants were sampled from only one province in South Africa.Middle ear pathologies in individuals living with HIV exist despite the efficacy of highly active antiretroviral treatment, albeit in small numbers when compared to treatment naïve individuals. If these pathologies are not detected and treated early, they may contribute significantly to the burden of hearing loss which already exists in developing countries. Tympanometry may not always accurately identify middle ear pathologies in individuals living with HIV. The use of video otoscopy in a complementary manner with tympanometry with 226 Hz may contribute to early and accurate identification of middle ear pathologies in this population. Moreover, the use of video otoscopy can contribute significantly in the accurate identification of middle ear pathologies, with the tele-practice capabilities presenting significant possibilities for access in resource-constrained contexts. Therefore, hearing health professionals need to consider using both video otoscopy and tympanometry with 226 Hz probe tone in order to get an accurate indication of middle ear function of not only individuals living with HIV but the general population as well.


Elevated levels of acyl chain saturation of meibomian lipids are associated with vastly different effects: from enhanced tear film (TF) stability in infants to shortened TF breakup time in meibomian gland disease patients. Thus it is important to study the effect of saturation on the surface properties of human meibum (MGS). Therefore, MGS films  were spread at the air/water interface of a Langmuir surface balance. The layers’ capability to reorganize during dynamic area changes was accessed via the surface pressure (π)-area (A) compression isotherms and step/relaxation dilatational rheology studies. Film structure was monitored with Brewster angle microscopy. The raise in the % (at ≥10%) of saturation resulted in the formation of stiffer, thicker, and more elastic films at π ≥ 12 mN/m with the effects being proportional to the saturation level. At the same time, at low (≤10 mN/m) π the raise in saturation resulted in altered spreading and heterogeneous structure of MGS layers. The strong impact of saturation on MGS surface properties correlates with our recent spectroscopy study, which demonstrated that saturation induced increase of MGS acyl chain order, phase transition temperature, and cooperativity. O-acyl)-ω-hydroxy fatty acids (OAHFA), and some phospholipids) [Human meibomian gland secretion (MGS), also termed meibum, is a composite lipid-rich mixture consisting of >90% nonpolar lipids (primarily wax- and sterol-esters and triacylglycerols) and <10% polar amphiphilic lipids, ((olipids) ,3,4. As olipids) ,6. Curreolipids) . A consiolipids) ,9,10,11.olipids) .The presence of double bonds (unsaturation) in the hydrocarbon chains of lipids affects the conformational order (fluidity) of meibum ,17,18,19Thus it is important to study the effect of varying effects of (un)saturation on the properties of human meibum. In our previous study , MGS fro−5 Hz range) and by exponential decay modeling of the relaxation transients [As the ultimate role of meibum in vivo is to spread on the tear surface and to contribute towards optimal functionality of TFLL, as a next step, the performance of these intact (0% saturation) and catalytically-saturated  MGS samples on the air/water surface is examined with Langmuir surface balance. Langmuir surface balance studies provide insights into factors that influence lipid film spreading and structure on an aqueous surface . For insansients ,39,40. Tmax) achieved at minimal surface area at the completion of film compression. As shown at panel B of max was 17mN/m for intact MGS (0% saturation) and, at ≥10% acyl chain saturation, πmax gradually rose with the level of catalytic saturation to reach 38 mN/m for 100% saturated MGS.The analysis of the surface pressure (π)/area (A) isotherms of MGS films , panel A−1 , see -1 from 8–10 mN/m (at 0–5% saturation of MGS) to 55 mN/m (at 100% saturated MGS), thus suggesting the formation of stiffer films with the raise of acyl chain saturation (at ≥10% saturation).The acyl chain saturation-induced changes in MGS material properties were well manifested in the dependence of the reciprocal compressibility modulus, Csmax and Cs−1 correlate with the similar effects of % of saturation on acyl chain order, phase transition temperature, and cooperativity found in our previous study [The lack of effect of ≤5% saturation on surface pressure/area isotherms and its proportionally increasing impact at ≥10% saturation on πus study .−1 dependencies [As reported in multiple studies ,12,38,39ndencies . At furtp ≥ 0.1 obtained by ANOVA comparison between the curves [The stress relaxation transients  of sample curves ) to the R, of the complex modulus, particularly at low, ≤10−3 Hz, frequencies and that the value of tan φ  decreased particularly in the frequency region of 10−3 to 10−1 Hz.The relaxation curves for intact MGS and for meibum with 25, 50, 67, and 100% acyl chain saturation were subjected (Equations (3) and (4) in IM vs. ER). The plots shown at panels A and B of R of 12 and 20 mN/m for intact MGS [It can be clearly seen that two peaks were observed in the Cole–Cole plots, at Etact MGS ,44. The tact MGS ,44,45,46EQ—plateau value.Here the number of exponents corresponds to the number of relaxation processes: A—pre-exponential factor reflecting the contribution of the individual term to the relaxation; τ—characteristic relaxation time; ΔπEQ to a spring element denoting equilibrium elasticity [i = ηi/Ei).In the framework of the generalized Maxwell model  is summarized at EQ value also increased, which reflects the rise of the plateau value of the surface pressure increment of the relaxation curves.As can be seen, two characteristic relaxation time regimes were observed, fast (τ < 0.8–3.3 s) and slow (τ = 32.7–42.6 s), with the pre-exponential factor of the “slow” exponent decreasing with the increase of acyl chain saturation. The ΔπElevated levels of acyl chain saturation of meibomian lipids occur both in infants and in MGD patients, and are associated with vastly different effects: from enhanced TF stability (in babies) to short NIBUT of TF (in people with MGD) ,27,28,29The current study shows that the rise in the % of acyl chain saturation results in formation of stiffer, thicker, and more elastic films at high π ≥ 12 mN/m) surface pressures with the effects being proportional to the level of saturation. It was found that, in order for the effects to become significant, acyl chain saturation should be ≥10%. These findings agree very well with our recent spectroscopic study, which demonstrated a similar impact of the % of saturation on acyl chain order, phase transition temperature, and cooperativity . These f mN/m surAt the same time, the increased cohesion between the acyl chains poses certain limitations as well. Namely, with the increase of lipid tail saturation, the spreading of MGS films was impaired, as manifested by (i) the increase in the lift off area, (ii) the shift of the saturated films’ isotherms to lower π values at ≥20% of the initial film area, and (iii) the heterogeneous structure of the meibomian layers (containing large dark regions separating the thick bright islands) at π ≤ 10 mN/m. Such observations align with the supposed qualitative deficiencies of MGD meibum ,16,17,18O-acyl) ω-hydroxy fatty acids (OAHFA), cholesteryl sulfate, and eventually phospholipids are significantly decreased in MGD [Thus, in order for the potential beneficial effects of acyl chain saturation to be harnessed, it is necessary the spreading of saturated MGS to be enhanced. In vivo at the ocular surface this can be done in two ways—via amphiphilic polar lipids and by tear proteins. Indeed, although the data on the type and amount of polar lipids in tears are still controversial, it is reported by independent groups that the levels of  or negative (impaired spreading) will depend on the availability of polar lipids and certain proteins in TF and on the interactions of MGS with these compounds ,4,12.The results have certain implications to pharmaceutical design as well. Ophthalmic formulations like eyedrops and topical (nano)emulsions may supplement the TFLL by range of oils that are generally recognized as safe and efficient ,12,39. U3. Half the pooled meibum was decanted to be catalytically hydrogenated. Saturated meibum was prepared as in our previous study [Meibum lipid was expressed from the eyelids of healthy volunteers with no signs of dry eye and was collected with a platinum spatula as previously described . The expus study . Platinuus study . The cat2, volume 100 mL  by the Wilhelmy wire probe method . The trough subphase was a physiological saline solution buffer . Human MGS , dissolved in chloroform, was deposited (35 µL of 1 mg/mL) over the air/saline surface with a microsyringe . The trough was positioned under an acrylic cover to protect the surface from dust and to suppress the evaporation of the saline solution subphase. After 15 min were given for chloroform evaporation, film compression was performed by two symmetrically-moving barriers. Dynamic compression–expansion isocycling of the layer area was done with the maximum barrier’s rate (70 mm/min), at which there was no film leakage. Ten consecutive cycles were performed with each film studied. Normally after the third cycle, the shape of the π(A) curves remained constant and those π(A) isotherms were presented and analyzed. All isotherms were repeated at least three times; the difference between the repetitions was less than 2%. The experiments were done at 35 °C, i.e., the physiological temperature of the ocular surface. The films’ morphology was monitored by Brewster Angle Microscopy .Surface pressure–area (π-A) isotherms were measured ,36,52 us−1, at a given surface pressure was calculated from π/A compression isotherms using the equation [−1 dependencies indicate the surface pressures at which significant reorganization of the surface film takes place in the course of the film compression.Film surface compressional modulus, Csequation :Cs−1 = 0, of 15 mN/m. Then, the lipid film was instantaneously and slightly contracted with a compression step, ∆A/Ao = 5 ± 1% . As discussed elsewhere [t − π0)/(πmax − π0) = f(t), where πt is the momental value of the surface pressure and πmax is its maximal value at the start of the relaxation. The dependence of the real, ER, and imaginary part, EIM, of the complex dilatational elasticity modulus E*(ν) on frequency, ν, can be obtained via Fourier transformation, F, of the relaxation transients [In order to gather information about the dilatational viscoelasticity of meibum films, intact and catalytically saturated, the relaxation of the surface pressure was monitored after a small rapid compression deformation was applied to the surface film. Firstly the film was compressed to initial surface pressure, πlsewhere ,54,55 noansients ,55,56:  accounts for the dissipative, viscous properties of the film. The number 6.28 is a brief denotement of the doubled Archimedes constant (2 × 3.14159…). The Fourier analysis of the relaxation transients was performed as previously described [Here Eescribed ,55,56 utR > EIM, then tan φ < 1 and the film is predominantly elastic. On the contrary, if ER < EIM, then tan φ > 1 and the film is predominantly viscous.After the real and imaginary parts of the complex modulus were calculated, the tangent of phase angle was computed:


This paper analyses the 2008 economic collapse in Spain with its long-lasting effects. Precisely, the ones associated with lifestyles. Thus, the aim of this paper is to examine to what extent economic downturns affect individual’s drinking behavior when focusing on unemployed people.We use discrete-choice models and matching techniques. Data from the National Health Survey for 2006 and 2011–2012 provides a clear picture before and after the 2008 breakdown in Spain.We find that drinking over the business cycle is a function of individual socio-demographic status. Besides, our empirical findings are consistent with the idea that following the crisis differences between unemployed and non-unemployed fell to at least in accordance with a lower overall consumption of alcoholic beverages.Public policy design for drinkers would require both prevention and recovery from alcohol use strategies to be met towards health and labour pillars.The online version of this article (10.1186/s12889-019-6882-2) contains supplementary material, which is available to authorized users. The study contains evidence on unlike drinking behavior over the business cycle.The episode analyzed is the 2008 economic collapse in Spain.Public policy design would require both prevention and recovery strategies.While it is generally acknowledged that long-term economic growth enhances health, the debate over the impact of short-term economic shifts remains open , 2. BasiThis paper contributes to the recent literature on the associations between economic crises and alcohol drinking behavior when considering Spain as a particular scenario . Two facThe aim of this paper is to examine the association between employment status and drinking behavior over the business cycle in Spain. It should be noted that this study does not examine the effect of alcohol consumption on labor supply. At the macro-level, this paper assesses whether alcohol abuse is associated with economic downturns, and if so to what extent. At the individual-level, the more relevant underlying pathway is the one from labor status from subjects who are prone to alcohol misuse. For both levels, we jointly focus on the Great Recession which started in 2008 as reflected in data collected from the Spanish National Health Survey (SNHS) in 2006 (before the crisis) and 2011–2012 (throughout the crisis). Taking advantage of the modern economic crisis, our goal is to analyze whether drinking patterns are driven by this episode. We use a unified framework embedding discrete-choice models and matching techniques. In doing so, we are able to assess the robustness of our results to alternative specifications.Several features distinguish this paper from previously published studies. First, this paper focuses on unemployment and alcohol consumption in Spain in terms of two opposite phases of the business cycle. Second, on the empirical side our paper highlights specific risks associated with economic conditions which provide crucial information when it comes to designing public-health policies. For the same reason, governments should be actively engaged and placing more emphasis on the impacts of health capital on the well-being of citizens.Y for individual i is represented as follows:A demand model can be used to illustrate how economic downturns are associated with drinking behavior . AlgebraW means wages, P represents prices, X denotes personal characteristics and ε indicates error term. It should be noted from Eq. (X), which include individual-specific characteristics.where from Eq.  that wagi is determined by:The formulation of the problem can be illustrated within the framework of Mullahy  and RuhmY is the number of drinks, X is some vector of individual-level characteristics, and E(·) and Pr(·) indicate conditional expectations and probabilities. The distinction between alcohol drinking participation and conditional alcohol drinking is standard in the health economics literature [Y as a result of comparing the utility of consuming a given (including zero) number of drinks with another number of drinks. The observability rule is Y = 1 (Y∗ > 0) for the binary choice of being a drinker or not being a drinker, or Y =  max  for the number of drinks consumed. Latent variable Y* is a linear function of labor status (being unemployed) and additional characteristics . The empirical counterpart to Eq. . Following Ayala and Rodríguez  and moreD = 1 means unemployed. Matching techniques are based on comparing two groups: (i) individuals who have received treatment (treated group), and (ii) individuals who have not received treatment but have similar characteristics as those who received it (control group). Hence, the second term on the right-hand side of Eq. . It therefore collects all changes  which occurred during this period and are not explained by the remaining explanatory variables. It should be noted from Eq.  and over the crisis (γ + θ). The advantage of this framework is that the economic crisis is safely assumed to be an exogenous shock, hence it is the dominant force for unemployment status. Therefore, looking at the effects on drinking behavior for 2006 avoids possible endogeneity biases from reverse causality [where from Eq.  that parausality .X associated with unemployment for the two periods. The parameter of interest to be estimated is the average treatment effect on the treated (ATT) of unemployment on the unemployed. Having calculated the propensity score, we applied different methods for correlation-making purposes: nearest-neighbor, radius, and kernel. Briefly, nearest-neighbor matching involve matching individuals by the propensity score with the smaller difference. As for the radius method, each individual is matched with one of more individuals in the “control group” whose propensity score is closer than a prefixed given number. Regarding the kernel, the “treated” individuals are compared with a weighted average of the “control” ones, being the weights inversely proportional to the distance between the propensity scores of these two groups. Finally, from Eq. . Comparable to other European health surveys, the objective is to obtain data from citizens regarding issues associated with health status and health-related behaviors. In this respect, two caveats need to be taken into account. First, the SNHS is not the typical periodical survey. We use the 2006 and 2011–2012 surveys because these are the available surveys for periods immediately before and after the Great Recession. By way of illustration, prior to 2006 only the 2003 survey was conducted, while survey data for the intervening years 2007–2010 are unavailable. Second, the 2011–2012 survey responders are not the same as the responders for 2006.n = 8015 (28.39%) whereas it is n = 6004 (28.94%) in 2011–2012. Absences are those that have the greatest weight in the non-response in 2006 (15.98%) while the absences are in 2011–2012 (14.61%). The surveys include different items regarding alcohol consumption. Since the sale of alcohol in Spain is limited to persons aged 18 years and over, it implies that the scope of the study was reduced to include adult working-age people in the age range of 18–65 years . As a result, the sample provided for 2006 comes down to 14,696, while for 2011–2012 is 14,981.Samples consist of 31,300 and 24,000 dwellings, distributed among 2236 and 2000 census sections, for 2006 and 2011–2012, respectively. It should be noted that the percentage of the total effective sample (96.11%t for 2006 and 89.62% for 2011–2012) can be considered as the response rate in each survey. This response rate represents the percentage of households that has been included in the practice (including substitutions). Regarding non-response in each survey, it is derived by refusals, absences and inabilities to answer. In the 2006 survey it gets drinker and drinking-frequency. For the former we created one dichotomous variable, coded 1 for those people consuming five or more drinks a week and 0 otherwise. In our sample 19.65% of the unemployed would be classified as drinkers in 2006, whereas this proportion has increased to 25.39% in 2011–2012. The second dependent variable measures the frequency of drinking without collecting the number of times; hence, it is not an ordered variable. This comprises four levels: 0 , 1 , 2 , and 3 . The econometric model we use in dealing with drinking-frequency is a multinomial one. Drinking on weekends versus weekdays is not really ordered, although drinking on both weekdays and weekends or neither could be considered ordered.We then outline by mean of operational definitions how to measure the consumption of someone drinking alcohol in order to define the subject’s score of dependent variables. Since questions concerning the subject vary somehow among surveys, these variables needs to be modified slightly. We are concerned about what impact this is likely to have on the study when trying to account for this by modifying the variables. It should be noted that we are limited by the variables included within the National Health Survey(s). That is to say, in both surveys respondents are asked whether they have consumed at least one drink of any alcohol beverage in the past two weeks, last year or a any previous time. Besides, other questions that are related with frequency of consumption. Differences between surveys are so, on how respondents are questioned but not at all in the final content of their answers that finally could be make uniform. Therefore, following Mossakowski , two proUnemployed is a dichotomous variable for labor status: 1 if the individual declares being unemployed, 0 otherwise. Gender, married, and nationality are also dichotomous variables. Notwithstanding, foreigner seems potentially quite heterogeneous since there are not enough observations to disentangle category (race/ethnicity). Age is a continuous variable ranging from 18 to 65 years as stated above following previous contributions  when thdrinker from Eq. . However, when time in unemployment is considered all variables are significant and positive, except long unemployment. It is consistent with both the provocation hypothesis and income hypothesis, attributing heavy alcohol drinking to stress caused by not being accustomed to being unemployed. Then, estimated coefficients on all but the lowest education levels show positive signs. But the crisis is significant not only in regard to being unemployed and education variables, being also significant concerning marital status. Therefore, the coefficient for being married is significantly negative in period 2011–2012, but not in 2006. In contrast, the estimates for age, gender , and nationality are robust to specification changes, the first two being positive, the coefficients associated with age are around 1.03 whereas male is about 4.56, and the third being negative, nationality gets 0.74, both before and during the crisis.Conversely, we reject from column 1 of the 2011–2012 survey that being unemployed have significant impacts on drinking-frequency. Table Next, we present evidence on the mechanisms driving Notwithstanding, an analysis of matching-techniques that provides comparisons of different points in the transition along the business cycle is conducted. Table Last, we consider how business cycles affect drinking patterns. To this end, we estimate Eq.  and repoOur results support previous research indicating that alcohol drinking is a pro-cyclical phenomenon . AccordiOur evidence also supports that alcohol drinking is largely a function of socioeconomic characteristics. More specifically, dual influences of education on alcohol abuse through the awareness of health capital and via income are expected. Similarly, family responsibilities would limit the participation in festivities and the risk of drinking alcohol to excess . This atGenerally, our findings allow policymakers to develop better intervention programs for improving health. Public policy design for alcohol consumers would require both prevention and recovery strategies to be met as goal towards constructing health and labor pillars. In light of the implications that can be drawn from the results of the empirical study, they may be helpful in driving interventions programs towards reducing alcohol consumption in population segments where it is more frequent, echoing earlier findings. The unemployed people usually drink more during recession, so the unemployed may warrant special intervention efforts. This is because new measures are required to recover competitiveness and to strengthen employment, by focusing on training and the updating of workers’ skills. In addition, it is worth highlighting that chronic drug consumption  reduces the probability of being employed . TherefoBut it is not the full picture since we should highlight the research limitations of the study. First, we refer to correlation between variables, not causation (that would require that changes in one variable would directly cause changes in the other one). It is important that one does not commit the ecological fallacy in the interpretation of statistical data . Here, iAll in all, more studies are needed to examine socioeconomic inequalities and the impact of the economic recession on health outcomes . ConsistThis paper contains new empirical evidence on drinking behavior over the business cycle. The episode analyzed was the 2008 economic collapse in Spain with its long-lasting effects, whereby high unemployment rates were included. We found that being unemployed prior to the crisis reduced the chance of alcohol drinking with regard to the employed. However, differences tended to vanish following the economic downturn along with lower overall alcoholic beverage consumption. Additionally, the present study showed that changes in alcohol consumption and drinking patterns were related to the characteristics of individuals. Hence, there were mixed reactions to the shock, depending on the education level and the gender, among other features.Additional file 1:Table A.1. Logistic Estimation from the Pooled Surveys. Dependent Variable: drinker.Table A.2. Multinomial Logit-model Estimation from the Pooled Surveys. Dependent Variable: drinking-frequency.Table A.3. Estimates of Drinking from Unemployment Changes Before and During the Crisis by Gender. (DOCX 38 kb)


The United States of America (USA), European Union (EU), Brazil and China are four of the largest agricultural producers and users of agricultural pesticides in the world. Comparing the inclination and ability of different regulatory agencies to ban or eliminate pesticides that have the most potential for harm to humans and the environment can provide a glimpse into the effectiveness of each nation’s pesticide regulatory laws and oversight.The approval status of more than 500 agricultural pesticides was identified in the USA, EU, Brazil and China and compared between nations. The amount of pesticides that were used in the USA and banned in these other nations was compiled and linear regression was used to identify trends in use.There are 72, 17, and 11 pesticides approved for outdoor agricultural applications in the USA that are banned or in the process of complete phase out in the EU, Brazil, and China, respectively. Of the pesticides used in USA agriculture in 2016, 322 million pounds were of pesticides banned in the EU, 26 million pounds were of pesticides banned in Brazil and 40 million pounds were of pesticides banned in China. Pesticides banned in the EU account for more than a quarter of all agricultural pesticide use in the USA. The majority of pesticides banned in at least two of these three nations have not appreciably decreased in the USA over the last 25 years and almost all have stayed constant or increased over the last 10 years.Many pesticides still widely used in the USA, at the level of tens to hundreds of millions of pounds annually, have been banned or are being phased out in the EU, China and Brazil. Of the pesticides banned in at least two of these nations, many have been implicated in acute pesticide poisonings in the USA and some are further restricted by individual states. The United States Environmental Protection Agency (US EPA) has all but abandoned its use of non-voluntary cancellations in recent years, making pesticide cancellation in the USA largely an exercise that requires consent by the regulated industry.The online version of this article (10.1186/s12940-019-0488-0) contains supplementary material, which is available to authorized users. Four of the largest agricultural producers in the world are the USA, EU, China, and Brazil – together accounting for more than half of all global agricultural production value . In addiMany agricultural practices can be harmful to humans and surrounding ecosystems and their potential benefits must be balanced against these harms . One widThe USA, EU, China, and Brazil each have separate and distinct pesticide regulatory systems designed to protect, to varying degrees, humans and the environment. The EU, consisting of 28 member states, currently has the most comprehensive and protective pesticide regulations of any major agricultural producer. The European Commission oversees pesticide approval, restriction and cancellation in the EU in accordance with Regulations 1107/2009 and 396/2005, which are designed to “…ensure that industry demonstrates that substances or products produced or placed on the market do not have any harmful effect on human or animal health or any unacceptable effects on the environment” and place the burden of proof on the pesticide industry to demonstrate that its product can be used in a way that does not result in harm to humans or the surrounding environment [In the USA, pesticide regulation is largely overseen by the US EPA, which regulates and enforces pesticide actions under the Federal Food, Drug, and Cosmetic Act (FFDCA) and the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) , 11. UnlHistorically, pesticide regulation in China has suffered from scattered data, complex laws and lack of transparency regarding rule implementation and compliance . RecentlBrazil’s pesticide regulations are overseen by three governmental agencies, the Brazilian MOA, Brazilian Health Regulatory Agency (ANVISA) and Ministry of the Environment (MOE) . Under BWhile regulatory agencies have many options to increase the safeguards for any given pesticide, including limiting what crops the pesticide can be used on, requiring safety equipment to be worn by applicators, requiring setbacks from sensitive habitats, and requiring management practices to minimize off-target movement, the most effective and reliable option is to ban a pesticide entirely if the potential for dangerous exposure cannot be feasibly mitigated. As such, one measure of the effectiveness of a regulatory agency is how it compares to its peer agencies in banning or eliminating pesticides that are most dangerous and have the most potential for harm to humans and the environment.A recent decision by former US EPA Administrator Scott Pruitt that reversed a planned ban on the pesticide chlorpyrifos, as well as the increasing influence of the agrochemical industry in the operations of US EPA, has called into question the effectiveness and robustness of pesticide regulation in the USA , 22. HerA list of more than 500 pesticide active ingredients that have been used in agriculture in the USA, EU, Brazil and China was compiled for use in comparing the approval status between nations  from those that were taken for economic or other reasons (not approved).Using the sources identified in Additional file The United States Geological Survey (USGS) National Water-Quality Assessment Project maintains an online resource of annual pesticide use estimates for all pesticides used in USA agriculture from 1992 forward . A descrp > 0.05), with the sole exception of oxytetracycline use over a 25-year period (p = 0.001).For trends in use over time, pesticide use data were obtained as described above from 1992 to 2016 for the following pesticides that are approved in the USA but banned or being phased out in at least two of the three compared nations: 2,4-DB, bensulide, chloropicrin, dichlobenil, dicrotophos, EPTC, norflurazon, oxytetracycline, paraquat, phorate, streptomycin, terbufos, and tribufos. Data were plotted over the 25-year period and over the most recent 10 years. To determine if pesticide use significantly changed over time, a linear regression was conducted for each pesticide over the 25- and 10-year period in SPSS for Windows version 25.0. To ensure normal distribution and homoscedasticity of residuals, pesticide use numbers from some pesticide datasets were natural logarithm-transformed prior to statistical analysis. Data were normally distributed for all datasets as measured by Shapiro-Wilk  class . Over 2000 incidents involving OPs were reported to poison control centers across the USA each year from 2012 to 2016 –40. The In addition to numerous incidents of acute poisonings, multiple states have determined that current US EPA regulations are not protective enough for some of these pesticides and have opted to place greater restrictions on use than the US EPA requires. California – the largest agricultural producing state in the USA by value – has imposed greater restrictions on chloropicrin, EPTC and norflurazon, including larger buffer zones, reduced acreage that can be treated, additional protective equipment and mitigations to prevent groundwater contamination –48. The Furthermore, two of the 13 pesticides, streptomycin and oxytetracycline, are antibiotics that are recognized as “critically” and “highly” important for human medicine by the World Health Organization (WHO), respectively . OveruseDuring this analysis it became clear that the USA utilizes voluntary (industry-initiated) cancellation as the primary method of prohibiting pesticides, which is different than the non-voluntary (regulator-initiated) cancellations/bans that predominate in the EU, Brazil and China. In fact, it is now almost exclusively the sole method the US EPA uses to cancel agricultural pesticides Fig. . There aOn the other hand, there are also instances when voluntary cancellations are used as a negotiating tool by the US EPA or would not have been requested without some amount of regulatory pressure. For instance, mevinphos was voluntarily cancelled in the USA by the registrant once the US EPA made it clear that it intended to suspend the pesticide due to human health concerns . With alOverall, voluntary cancellations in the USA appear to have played a role in facilitating the removal of some potentially hazardous pesticides. But while voluntary cancellations have one benefit—that being a certainty that the cancellation will not be challenged in court by the pesticide registrant—there are notable downsides to using this as the primary method of cancelling pesticides. The major one being that it requires at least some desire on the part of the pesticide registrant. All 10 agricultural OP pesticides that were voluntarily cancelled in the USA after 2002 had already steeply decreased in use before they were cancelled, suggesting that the economic benefits of their continued registration were not as favorable to the pesticide industry Additional file 2:Sources used to compile the final list of agricultural pesticides. (XLSX 39 kb)Additional file 3:Approval status of agricultural pesticides in the USA, EU, China and Brazil. (XLSX 133 kb)Additional file 4:Total pesticide use in the USA in 2016 itemized by active ingredient. (XLSX 14860 kb)Additional file 5:Total use of pesticides in the USA in 2016 that are banned, being phased out or not approved in other agricultural nations. (XLSX 35 kb)Additional file 6:Trends in use of pesticides in the USA that are banned in at least two of three other agricultural nations (2007–2016). (PDF 578 kb)


To describe the development of a preventive educational video for patients exposed to whiplash trauma following motor vehicle accidents.The development followed a systematic approach and was theory-driven supplemented with available empirical knowledge. The specific content was developed by a multidisciplinary group involving health professionals and visual production specialists.A 14-min educational video was created. The video content focuses on stimulating adaptive recovery expectations and preventing maladaptive illness beliefs. The video presents a multifactorial model for pain incorporating physiological and cognitive-behavioural aspects, advice on pain relief, and exercises. Subjects interviewed for a qualitative evaluation found the video reassuring and that it aligned well with verbal information received in the hospital.The development of the visual educational intervention benefitted from a systematic development approach entailing both theoretical and research-based knowledge. The sparse evidence on educational information for acute whiplash trauma posed a challenge for creating content. Further knowledge is required regarding what assists recovery in the early stages of whiplash injuries in order to improve the development of educational interventions. Whiplash injuries following motor vehicle collisions affect an estimated 1–3 per 1000 inhabitants each year –4. An esCurrently, no specific treatment is available for standard care due to the lack of consistent evidence for the effectiveness of any treatment strategy , 17. ManThe recommendations for providing patient education reflect evidence that early mobilization and advice to act as usual may improve recovery to some extent , 19. FurSeveral studies have found an association between early pessimistic illness beliefs and expectations and poor recovery rates –34. ThesThe verbal information provided in the emergency room immediately after the accident is often the only patient education affected individuals receive . The timProviding patient education online in a visual form could be a pragmatic expansion of the face-to-face information in the emergency room. Video education is equal to face-to-face information when it comes to improving patient knowledge and may also promote behavioural changes and improved self-care . VisuallSo far, only two studies have attempted using patient education by video for whiplash injuries , 42. A COn the basis of the aforementioned studies, we aimed to develop a novel educational video for individuals presenting in Danish emergency rooms with pain complaints after whiplash trauma. The goal was to expand the verbal information that is provided as standard care with information specifically aimed at promoting adaptive beliefs about the nature and the course of the injury. The development of the intervention took place during the preparatory phase for a randomized controlled trial aimed at testing the effectiveness of an educational video on subsequent pain levels, disability, and work ability following acute whiplash trauma.Interventions are often developed in an ad hoc fashion without an extensive theoretical or empirical foundation . This maThe target population for the educational video was specified as persons exposed to a likely whiplash trauma during a motor vehicle accident and seeking care in an emergency room due to acute neck complaints. Fractures, concussions, or any other direct trauma or injury were excluded. The intended recipients thus correspond to whiplash-associated disorder (WAD), grades 1–3 as specified in the Quebec Task Force classification . The intA multidisciplinary group responsible for the development and the content of the intervention was established. The group consisted of a neurologist with expertise on whiplash and pain treatment, a psychiatrist specializing in functional somatic syndromes, a psychologist with expertise on illness perception and cognitive behavioural therapies, a photographer with extensive experience in video production for patient information within the hospital-based healthcare system, and an experienced animator. A second psychologist familiar with pain treatment acted as the coordinator for the group and was responsible for writing the draft for the intervention. Other health care professionals were consulted for advice during the different stages of the development process. Amongst these were a consultant from an emergency department, a physiotherapist, a physician specializing in the treatment of chronic bodily symptoms, and a psychologist specializing in whiplash.The multidisciplinary group focused on one key theoretical concept as a theoretical framework for the development of the visual material, namely the common sense model of illness developed by Leventhal and colleagues . The modBy addressing the five components of IP, we aimed at increasing the patients’ ability to cope appropriately with acute symptoms and thereby preventing the transition to prolonged pain. Furthermore, the intention was to counteract misconceptions and possible myths surrounding whiplash injuries –52. ExamWhile the concept of IP provided an overall frame and goals for the intervention, the information specific to whiplash injuries was extracted from empirical research. An earlier review of available scientific evidence concerning prognosis and management of whiplash-related injuries  was usedMedline and Cochrane Database of Systematic Reviews were searched for papers published in the preceding 10 years (2001–2011) containing the term “whiplash injuries”. All titles and abstracts were examined to evaluate relevance. Especially, studies related to patient expectations and beliefs were considered due to the chosen emphasis on promoting optimistic IP. Fear of movement and self-efficacy –62 were Two studies on video education aimed at acute whiplash trauma , 42 wereThe next step was setting a structure and shaping the visual and verbal narrative of the video. A time frame of 10–15 min in length was set for the video. This was deemed a proper compromise between having enough time to provide adequate information without overtaxing the attention span of patients with pain and possibly difficulties sustaining attention. Discussions were focused on deciding what specific information to represent and finding the balance between different types of information . The group developed ideas for the visual representations needed to convey the intended message and discussed the overall balance between suggested animations and footage of patients and professionals. On the basis of research on patient education through video , 40 suggSelected elements from the aforementioned American and Canadian videos , 42 wereThe work within the multidisciplinary group resulted in a detailed manuscript for a video with an estimated length of 15 min. The manuscript contained both the exact phrasing of the verbal content and a description of the visual representation including the different scenarios and persons that should be featured as well as suggested animations, graphs, and exercises. The detailed manuscript was presented to a medical consultant and a physiotherapist with extensive experience with patients suffering persistent symptoms after whiplash traumas. The responses to the manuscript were considered by the multidisciplinary group, and final adjustments were made to the manuscript. The comments were primarily concerned with adjustments to the phrasing of the verbal content, and while achieving complete agreement on all comments was not possible, a satisfactory compromise was reached.The manuscript was reworked by the coordinator, photographer, and animator from the Department of Communication at Aarhus University Hospital. The visual structure of each segment of the video, including a detailed plan for visual scenes, flow of the images, and the appearance of animations and graphics, was made in a manner equivalent to creating a storyboard. The final manuscript was then reviewed and approved by the multidisciplinary group.The video sequences were filmed over a period of 2 months at different locations with simultaneous development of the animations. We used a combination of filmed sequences with doctors and patients coupled with animations and graphs  receiving the video after their visit to the emergency room were interviewed and gave account of their experience of the information.All the patients felt the video was acceptable and that it had been a positive experience to receive the intervention. Likewise, they all felt the content was relevant, helpful, and reassuring to watch. They also noted that the content was readily understandable and corresponded well to the information they were given by staff in the emergency room. All four preferred to receive a video instead of written material.Two patients explained that it was helpful to watch the information at home as they were distraught and in pain when they were in the emergency room. They therefore found it difficult to focus on the information provided by the staff. Only one out of four had used the exercises presented, and this one patient found them helpful and attributed her ability to use them to the visual presentation. One patient noted that he did not actively use any of the information in the video but felt that it had a calming effect on him and made him feel that the hospital staff took his pain seriously. Another patient noted that he had difficulties assessing how much pain he should tolerate during movement and would have liked more specific information about this.This paper describes the process of developing a brief educational video for acute whiplash injuries. In many cases, new interventions are not developed in a systematic transparent manner or described in detail making it a challenge to interpret and replicate studies. It is a clear strength of the current study that we used a structured model for the development of the intervention. Furthermore, it is an advantage that we involved a multidisciplinary team and personnel with expertise in visual media from the very beginning as recommended by Williams and colleagues . In addiWhile the systematic approach to developing visual interventions is recommendable, it is also time-consuming and requires the involvement of personnel from different disciplines, all of which can pose a challenge in a busy hospital setting. It is a possible weakness of this study that the patients’ perspective was not included to a higher degree at the very inception of the video. For future projects, it would be recommendable to take a more patient participatory approach. This could be achieved through a qualitative examination of patients’ wishes for information before filming is initiated or by including patients as members of the multidisciplinary development group. Doing so would in all likelihood ensure the best possible match between patients’ needs and the final product. Ideally, we should also have included an extensive qualitative testing of the video segments early in the development process before reaching a final edit. This was originally proposed by Williams and colleagues , but we The video was specifically tailored to provide optimistic expectations concerning recovery. However, it is a point for discussion whether or not one ought to include information about the possibility for experiencing prolonged symptoms. As pointed out by Rebbeck , guideliThe major challenges we faced during the development of the video were not related to the systematic approach itself but rather reflected the state of the available empirical evidence. The sparse number of prior interventions, which have proven helpful in aiding recovery, meant that the choice on video content relied heavily on knowledge on prognostic factors as opposed to content with an established impact on recovery. Another challenge we faced while reviewing the scientific literature as guidance to the information was the broad range of risk factors associated with persistent pain after whiplash trauma , 73. SevFurther complicating the matter, studies suggest that patients affected by whiplash trauma are a heterogeneous group involving subgroups with significant differences in clinical outcome , 33. CreAside from the challenges of tailoring evidence-based content, video can be a practical tool for standardized patient education that is easy to implement once created. Since time has moved beyond reliance on physical devices such as DVDs, creating an Internet-delivered solution is in our view the most pragmatic strategy for implementation. Due to the widespread use of electronic devices with access to the Internet in the general population, providing access online will make the intervention relatively cheap to disseminate. It means patients can watch the information in the waiting area of the hospital, on the commute home, at home, or at work at their own discretion. We therefore believe that Internet-based videos will be an important tool for disseminating health-related information in the future.An educational video for acute whiplash injuries was developed by a systematic approach. The model guiding the development process proved helpful in combining theoretical considerations, e.g. illness beliefs, with available empirical knowledge on whiplash injuries. Furthermore, the approach ensures that extensive consideration is given to the development of conceptual and visual content without compromising the importance of incorporating both theoretical and evidence-based knowledge. The strategy can easily be adapted to other patient groups and settings provided that the required personnel and technical resources are available.The primary obstacles in the development process were not the requirements of the systematic approach but the relatively sparse scientific evidence on information expected to promote recovery after whiplash trauma. More extensive knowledge is required regarding what assists or hampers recovery in the early phase after injury in order to guide the information presented to patients.Clinicaltrials.gov ID: NCT01699334).The effectiveness of the educational video presented here is currently being tested in a randomized controlled trial (


However, subsequent case series have done little to quantify the effect of ICG VA on outcomes. The available literature predominately concludes that ICG VA, although intuitive to deploy and interpret, is limited by its dependence on direct illumination and visualization. The subcortical components of AVMs represent a natural challenge to ICG-based flow analysis, and the scope of ICG VA has therefore been limited to AVMs with a high proportion of superficial angioarchitecture. As a result, digital subtraction angiography has remained the gold standard for confirming AVM obliteration. In this review, we provide an overview of the existing literature on ICG VA in AVM resection surgery. In addition, we describe our own experiences with ICG VA and AVMs and offer the senior author's surgical pearls for optimizing the marriage of fluorescence flow technology and AVM resection surgery.Indocyanine green (ICG) is a fluorescent molecule that enables visualization of hemodynamic flow through blood vessels. The first description of its application to the resection of arteriovenous malformations (AVMs) did not occur until 2007. Since then, industry leaders have rapidly integrated this optical technology into the intraoperative microscope, and the use of ICG videoangiography (VA) has since become routine in AVM surgery among some academic centers. A number of case series have been published since the introduction of ICG VA to AVM neurosurgery. These early reports with small sample sizes were largely qualitative, assigning to the technology “usefulness” and “benefit” scores as perceived by the operators. This lack of objectivity prompted the development of FLOW 800 software, a proprietary technology of Carl Zeiss Meditec AG  that can quantify relative fluorescence intensity under the microscope to generate color maps and intensity curves for  A tenant of any neurosurgical operation is the maintenance of perfusion by way of avoiding undue vascular compromise. In the resection of intracerebral arteriovenous malformations (AVMs), this means the exclusion of en passage  vessels as well as the protection of nidal draining veins until arterial feeders have been disconnected . IndocyaSince its introduction to the field, the utility of ICG VA in optimizing the margins of safety during AVM resection has become more widely accepted. Now, some authors would posit that ICG VA is a standard component of AVM resection surgery . Both siICG dye was first introduced to the field of medicine after its approval by the Food and Drug Administration in 1956  applied 43H47N2NaO6S2) is a water-soluble molecule with a molecular weight of 744 g/mol (2O) bolus  bolus –17 is inO) bolus . It alsoO) bolus . With itThis combination of physical and pharmacological characteristics makes ICG an ideal choice for delineating superficial AVM anatomy and excluding intervening brain parenchyma. Although near-infrared fluoroscopy has been shown to “penetrate several centimeters into tissue” , 19, theThe 2007 report by Takagi et al.  is the oKillory et al.  were theOne year later, Ferroli et al.  publisheThat same year, more than 500 miles away, neurosurgeons in Germany reported similar results in 15 patients with an AVM . The resNearly 9,000 miles from their German colleagues, Khurana et al.  assessedPerhaps summarizing 2010's international experience with ICG VA in AVM surgeries, Wang et al.  concludeThe first article describing the use of FLOW 800 quantitative software was published in 2011. Just 4 years after the first publication on ICG VA and AVM surgery, Faber et al.  via laseIn the report by Faber et al. , this teAfter their influential first report, Takagi et al.  and Kampin situ.Ng et al.  further In 2014, the Spetzler group published what is thought to be the largest consecutive case series of ICG VA in AVM surgery to date . They reA 2015 study of 7 patients who underwent ICG VA–mediated AVM resection by Fukuda et al.  resultedVascular malformations of the spinal cord are grossly similar to their intracranial counterparts, yet are also distinct entities that require a specialized surgical approach. There are far fewer available data regarding the application of ICG VA techniques to these lesions in the neurosurgical library because, in part, of their overall lower incidence . NeverthThese published reports, though limited to single institution case series, reflect on several years of operator experience in applying ICA VA to the resection of spinal AVMs. They represent a small but apparently growing consensus on ICG VA's usefulness to these challenging operations. Although far more research is needed to address the current paucity of published data on the matter, these foundational case series are sparking innovation and unique applications of their own. In a recent study by Hamauchi et al. , ICG wasThe limitations previously discussed are perhaps unsurprising to the neurosurgical community at large. The predominately deep-to-superficial anatomical arrangement of intracranial vessels inherently limits any modality that relies on direct visualization and illumination. Today, no means to fully rectify this limitation has been found, but it still might be attenuated by a combination of operator experience and deft applications of the technology. For example, in 2017, one such experienced group published a video documenting their surgical treatment of a large, eloquently located frontoparietal SMG III AVM in a 31-year-old man who presented with hemiparesis after the malformation ruptured . The chaen passage vessels. Of note, to accurately evaluate ICG VA intraoperatively, it is necessary to position the operative microscope at a predefined distance from the operative field and adjust the zoom and focus accordingly. These variables are dependent upon the microscope, and one should consult the microscope's user manual prior to the case.The senior author recently published his experience using ICG VA in a small group of patients who were undergoing cerebrovascular neurosurgery  Figure . FLOW 80In 2 of these cases, careful study of the resultant maps enabled the disconnection of an arterialized draining vein and preservation of crucial normal venous drainage. In another illustrative case of a medial parasagittal AVM, mobilization of the hemisphere was made possible after ICG VA enabled the operator to discern high-throughput cortical arterialized bridging veins from those less vigorously irrigated and therefore safe for sacrifice. To our knowledge, this application of the technology is not represented elsewhere in the literature. Although it requires a coupling of comfort with the interhemispheric approach and confidence in interpreting color map data, quantified ICG VA can be cautiously adapted for this purpose.en passage vessel stenosis. The integrated FLOW 800–capable operative microscope makes evaluation in these cases especially easy by obviating the need to rearrange surgical equipment during the operation. In fact, at least 1 study found ICG VA to be statistically significantly faster to deploy than DSA (Nuanced quantitative ICG VA color mapping is particularly useful in a subset of AVMs with specific characteristics, as previous studies have concluded. Intraoperative fluorescent flow analysis directly influenced dissection strategies in each of the cases in the senior author's study. We find ICG VA to be most effective when judicious patient and lesion selection has occurred. For example, superficial AVM anatomy may appear obscured to the naked eye because of overlying dense arachnoid bands. In these cases, ICG VA makes an important contribution to the surgical stratagem by providing real-time data on vascular structures that would otherwise have to be dissected blindly and therefore haphazardly, guided by direct visualization alone. It is also regularly used, in our experience, when there is concern for inadvertent clip-induced than DSA .The additional time needed to perform DSA might nevertheless be warranted by the equipoise of safety in some situations. For example, in a 2013 article, Kono et al.  describeOur team has also used fluorescein in place of the ICG and has found reasonable results similar to those of the ICG , 42. TheAltogether, these data make a strong argument for the role of ICG VA as an adjunct modality in AVM surgery, fulfilling a specific purpose with relative ease in a specific group of lesions. This general gestalt seems to be shared by other experienced operators at high-volume centers , 33. DesStudies unanimously agree that ICG VA with FLOW 800 quantitative analysis is an accurate method of delineating superficial AVM structures, but it suffers in regard to deeper structures. In our opinion and experience, it can be used effectively to guide cortical entry points for subcortical dissections and to inform the safe sacrifice of tethering secondary cortical arterialized veins in certain surgical approaches. Likewise, the generated color maps of FLOW 800 are practical, easily interpreted intraoperatively, and sufficient for guiding surgical resection. Although ICG VA has advantages over DSA in terms of deployment speed and ease of use, its inability to visualize subcortical AVM components remains a looming obstacle. Therefore, DSA remains the gold-standard method of confirming complete AVM occlusion .Only 1 systematic review  and 2 geCF performed literature review, synthesized data, and prepared the draft of the final manuscript. PM reviewed, edited, and augmented the drafted manuscript. ST assisted with gathering and contributing data for the drafting of the manuscript. AC-G reviewed and edited the drafted manuscript, provided expertise to technical portions of the manuscript, and provided supervisory support.AC-G is a consultant for Carl Zeiss Meditec AG. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Binge drinking, defined as consuming five or more standard alcoholic drinks for men (four for women) within a 2-hour period, is common among young adults and is associated with significant alcohol-related morbidity and mortality. To date, most research on this problem in young adults has relied upon retrospective questionnaires or costly laboratory-based procedures. Smartphone-based ecological momentary assessment (EMA) may address these limitations by allowing researchers to measure alcohol use and related consequences in real time and in drinkers’ natural environments. To date, however, relatively less research has systematically examined the utility of this approach in a sample of young adults targeting real-world heavy drinking episodes specifically.This study aimed to evaluate the feasibility, acceptability, and safety of a smartphone-based EMA method targeting binge drinking and related outcomes in heavy drinking young adults during real-world drinking occasions.Young adult binge drinkers in the smartphone group  years; 58% (48/83) male; bingeing on 23.2% (6.5/28) days in the past month) completed baseline measures of alcohol use and drinking-related consequences, followed by up to two smartphone-based EMA sessions of typical drinking behavior and related outcomes in their natural environments. They also completed next-day and two-week follow-up surveys further assessing alcohol use and related consequences during the EMA sessions and two weeks after study participation, respectively. A separate demographic- and drinking-matched safety comparison group (N=25) completed the baseline and two-week follow-up surveys but did not complete EMA of real-world drinking behavior.Most participants  in the smartphone group engaged in binge drinking during at least one 3-hour EMA session, consuming 7.3 (SD 3.0) standard alcoholic drinks. They completed 87.2% (507/581) system-initiated EMA prompts during the real-world drinking episode, supporting the feasibility of this approach. The procedure was acceptable, as evidenced by high participant ratings for overall satisfaction with the EMA software and study procedures and low ratings for intrusiveness of the mobile surveys. Regarding safety, participants endorsed few drinking-related consequences during or after the real-world drinking episode, with no adverse or serious adverse events reported. There were no differences between the groups in terms of changes in drinking behavior or consequences from baseline to two-week follow-up.This study provided preliminary support for the feasibility, acceptability, and safety of a smartphone-based EMA of real-time alcohol use and related outcomes in young adult heavy drinkers. The results suggest that young adults can use smartphones to safely monitor drinking even during very heavy drinking episodes. Smartphone-based EMA has strong potential to inform future research on the epidemiology of and intervention for alcohol use disorder by providing researchers with an efficient and inexpensive way to capture large amounts of data on real-world drinking behavior and consequences. Binge drinking, also known as heavy episodic drinking, is a significant public health problem in the United States and accounts for more than half of the 88,000 alcohol-related deaths in the United States each year ,2. ApproPrior research has used EMA to measure real-world light-to-moderate alcohol use  with good compliance across studies  -15. EMA Given our current era of rapid advances in mobile technology and changing user preferences, the modality of alcohol monitoring is important. Most prior EMA studies of drinking have employed either palmtop computers  or olderTherefore, the purpose of this study was to evaluate the feasibility, acceptability, and safety of a real-time smartphone-based EMA method to obtain self-reported alcohol use and related outcomes  during real-world drinking events in young adult heavy drinkers. We targeted the EMA procedure in this study toward binge drinking episodes specifically because previous work in this field has focused mainly on capturing drinking behavior generally over a period, for example, several days or weeks ,16,19, rThe Mobile Alcohol Response Study was conducted between April 2017 and June 2018 and employed a within-subject design with each participant undergoing 1 or 2 separate real-time smartphone assessments of typical drinking episodes in their natural environment. As stated above, a separate safety comparison sample completed baseline and follow-up surveys of drinking behavior and related outcomes but did not undergo real-time mobile monitoring. As part of a larger study, participants also completed a laboratory session with alcohol administration to validate the smartphone-based EMA method; those data will be reported elsewhere. All study procedures were approved by the University of Chicago Institutional Review Board.Candidates were recruited from Web-based advertisements and word-of-mouth referrals. Inclusion criteria were age 21 to 29 years, generally healthy young adults with weekly heavy alcohol consumption  for at . The surveys included the Alcohol Use Disorder Identification Test −(60β × t), where c is the number of standard drinks consumed to that point in the drinking episode, GC is a gender constant (7.5 for men and 9.0 for women), w is weight in pounds, 60β is a constant representing the average population alcohol metabolism rate (0.017 g/dl per hour), and t is the time in hours since drinking began. We assumed that participants consumed the first drink in the episode over 20 min when calculating t, as in previous studies [Feasibility was examined by (1) the percentage of nonparticipant-initiated prompts completed and (2) the estimated number of standard drinks reported at each time point. The number of estimated standard drinks consumed was used to determine the percentage of episodes that included heavy drinking. In addition, this information was used to estimate BAC  levels throughout the drinking episode according to the equation of Matthews and Miller : eBAC=[ analyses examining group, time, and their interaction. Skewed data were log-transformed before analysis, as appropriate.Examination of data from the mobile assessments revealed that a high majority of participants correctly recorded their drinking during the drinking episode . Despite training participants during screening to indicate only the number of drinks finished since the prior EMA prompt, 4 participants incorrectly reported their cumulative number of drinks at each prompt instead. Thus, their data could not be interpreted, resulting in a final study sample of 83 participants. eBAC calculated for a small number of survey responses was ≥0.30 g/dl, a level of intoxication associated with loss of consciousness or death. We assumed that those time points reflected errors in reporting  and opteAll participants completed the self-initiated baseline and post first-drink survey prompts and 87.2% (507/581) of the remaining 7 system-initiated prompts over the ensuing 3 hours of the EMA session . Most paParticipants reported consuming any alcohol on 75.4% (445/590) of 590 completed prompts from the self-initiated post first-drink survey onward . They consumed 7.3 (SD 3.0) standard drinks during the 3-hour drinking assessment, with eBAC reaching 0.13 (SD 0.07) g/dL at the final time point  had high response rates and completed all the study prompts (9/9) with an average of 8.1 and 8.3 prompts completed in the first and second episodes, respectively. There was more drinking alone during the second episode  than the first . Participants’ reported location when completing the prompts or consumption of food, nicotine, or other drugs did not differ across assessment sessions, all Ps>.07.Background characteristics and alcohol consumption during drinking episodes did not differ between participants who completed 2 smartphone drinking assessments  and those who completed 1 assessment (n=22), all P=.02), but other acceptability ratings did not differ based upon the number of smartphone sessions completed (Ps>.16).Participants rated the smartphone survey software as easy to use overall  and endorsed high satisfaction with study participation . Similarly, participants did not consider the surveys to be time consuming  or intrusive . Overall, participants agreed that they would recommend participation in the study to others . Intrusiveness ratings were slightly higher among participants who completed only 1 smartphone assessment than among those who completed 2 assessments  of participants in the smartphone group completed the next-day survey after the real-world drinking episode. Most participants  reported continued drinking after the final survey prompt for the episode see . ParticiP=.008), but binge drinking frequency and drinks consumed per drinking day did not change for either group (Ps>.12). There was a significant increase in self-reported alcohol consequences from baseline to 2-week follow-up .GEE revealed that self-reported drinking frequency decreased at follow-up for both the smartphone and control groups  completed the EMA protocol in the setting of a drinking binge. The smartphone-based approach was feasible, as evidenced by a high response rate  to system-initiated study prompts during the 3-hour assessment period, and acceptable, with participants reporting high satisfaction study procedures and low ratings on intrusiveness for the brief (1 min each) EMA surveys. Safety was evidenced by few drinking-related consequences and no increases in drinking quantity or frequency over the 2-week follow-up. The results of this study show that young adult heavy drinkers can complete mobile assessments of their drinking behavior and related outcomes even during very heavy drinking episodes at BAC well over the threshold for intoxication. The method described here is user-friendly and easy to administer on participants’ own smartphones and could be customized to facilitate future research on a variety of topics related to risky drinking. Furthermore, it may be less susceptible than retrospective or laboratory-based studies of binge drinking outcomes to limitations posed by recall bias and unclear ecological validity, respectively.typical drinking.Relative to prior EMA studies in social drinkers, our 87% response rate to survey prompts is similar to, or higher than, response rates reported in previous studies ,12-15. NRegarding feasibility and acceptability of the EMA approach, participants reported good compliance with study directions to avoid alcohol or other drug use during the assessments and high overall satisfaction with study procedures. The data from this study suggest that heavy drinkers can comply with instructions to avoid those substances even during binge episodes with high BAC and that this approach can produce data on drinking-related outcomes that are contaminated only minimally by other substance use. The high acceptability ratings reported in this study echo previous findings from EMA studies in general young adult drinker samples ,36. The Importantly, the results of this study suggest that EMA of a real-world binge drinking episode in heavy drinkers is safe. Participants reported few alcohol-related problems during the drinking episode, and those that were reported tended to be minor . Both groups reported a small decrease in their frequency of alcohol use from baseline to 2-week follow-up, with no changes in binge drinking frequency. This finding is in line with the results of previous studies indicating that EMA of alcohol use is associated with minimal or no changes in reported drinking behavior ,37-39. HThis study featured several strengths, including a well-characterized sample of young adult heavy drinkers, application of existing mobile phone technology to support EMA of real-world heavy drinking and related outcomes, and inclusion of an independent heavy drinking sample as a safety comparison group. However, there are also some limitations worth noting. First, although we recruited current binge drinkers, light drinkers and those meeting criteria for severe AUD were excluded from participation. Thus, based on the current data, we cannot infer the feasibility, acceptability, or safety of our smartphone-based EMA approach in those groups. Second, the duration of our monitoring period  was brief and fixed, in contrast to previous studies that have assessed alcohol use outcomes over several weeks  and scalIn sum, the results of this study provide preliminary support for the feasibility, acceptability, and safety of using smartphone-based EMA to assess alcohol use and related outcomes  in young adult heavy drinkers. These data suggest that young adults can use smartphones to monitor their drinking even during very heavy drinking episodes, with average consumption approximately double (or more) that of previous work in this field ,11,14,35