N = 15). This approach, of scoring open-ended immediate free recall of the stimulus, is applicable not only to video, but also to other situations where a measure of the information that is successfully acquired is desirable. Information acquired will be affected by stimulus quality, sensory ability, and cognitive processes, so our metric can be used to assess each of these components when the others are controlled.Information acquisition, the gathering and interpretation of sensory information, is a basic function of mobile organisms. We describe a new method for measuring this ability in humans, using free-recall responses to sensory stimuli which are scored objectively using a “wisdom of crowds” approach. As an example, we demonstrate this metric using perception of video stimuli. Immediately after viewing a 30 s video clip, subjects responded to a prompt to give a short description of the clip in natural language. These responses were scored automatically by comparison to a dataset of responses to the same clip by normally-sighted viewers (the crowd). In this case, the normative dataset consisted of responses to 200 clips by 60 subjects who were stratified by age (range 22 to 85y) and viewed the clips in the lab, for 2,400 responses, and by 99 crowdsourced participants (age range 20 to 66y) who viewed clips in their Web browser, for 4,000 responses. We compared different algorithms for computing these similarities and found that a simple count of the words in common had the best performance. It correctly matched 75% of the lab-sourced and 95% of crowdsourced responses to their corresponding clips. We validated the measure by showing that when the amount of information in the clip was degraded using defocus lenses, the shared word score decreased across the five predetermined visual-acuity levels, demonstrating a dose-response effect ( Mobile organisms are continually gathering information about their environment, and acting on it. The information arrives via sensory organs, such as eyes and ears, and must then be processed to derive usable facts about the world. This process is limited not only by the fidelity of the information source, but also by the organism’s sensory and cognitive processing ability. Since these sources of error jointly determine the organism’s functional capabilities, there is a pressing need for performance metrics of information acquisition. Existing approaches have focused on each of these stages in isolation, e.g. with computational models of information quality This method could be used with high-level perception in any sensory modality, but we developed it in our search for an objective metric for video quality. In particular, as a method for assessing the benefit of image enhancement for people with vision loss. Modern digital image processing has the potential to modify images to make them more visible to people with vision impairment. It is increasingly feasible to apply such modifications to video in real time, which could improve the accessibility of television and movies. However, there is a lack of well-established, objective techniques for evaluating the potential benefit of image enhancement A limitation of these methods is that they rely only on subjective impressions of video quality, and do not include direct assessment of whether an enhancement aids performance. In the domain of watching video for recreation (e.g. television), it is difficult to define what constitutes task performance. This, despite TV watching being an activity to which many adults devote a significant portion of their leisure time, find a benefit from as a source of relaxation, use as a way to spend time with other people, and learn from about the world and their community. A potential objective approach to assessing TV watching is to measure the quantity and accuracy of information that is acquired by the viewer while watching. Most aspects of vision  are engaged when watching a TV program, and if any of these abilities are degraded, information acquisition will be affected. Similarly, degrading or enhancing (in an effective way) the video may also be able to affect information acquisition. Although people more often watch TV for enjoyment than specifically to acquire information (e.g. news), here we are considering the relevant information to be any content that needs to be understood to follow and appreciate the content of the video. That information could include the identity of the people on screen, facial expressions or the nature of the setting, without which the viewing experience may not be coherent or pleasurable. For a short video, much of the information that is acquired should be available to the viewer to report immediately after viewing.In the related domain of reading comprehension, many studies have attempted to measure information acquisition from reading material, using multiple choice questions, replacement of deleted words, or immediate free recall Two studies that directly measured information acquisition in the domain of video used quizzes about the content of TV episodes developed from the corresponding Assistive Description scripts Our solution to the need for objective and unbiased evaluation of the content of a natural-language response involves presentation of the stimulus to a suitable group of people to generate a reference dataset. A new response to that stimulus is then compared to these “normal” responses. The comparison is made using an objective approach that can be broadly categorized as computational linguistics, though the most successful algorithm that we have identified so far is surprisingly simple.As an illustration of this new information acquisition metric, we describe its use for video stimuli: 30 s segments from Hollywood films and documentaries. In response to an open-ended prompt immediately after viewing, subjects gave a natural-language description of what they could recall about the video clip. Automated scoring algorithms were evaluated, and we report an experiment which validated the method using artificially degraded vision.Free-recall methods for measuring information acquisition, such as those used in reading comprehension, typically score the responses using a manual coding system Therefore, rather than scoring the free-recall descriptions of the video clips manually using one of these systems, we developed an automated scoring strategy. Our algorithms compare responses to a normative dataset of responses to the same video clips. This approach is similar to one that has been used to evaluate machine translations For most media clips, a gold standard is not available, and the development and validation of a gold standard would require significant experimental effort, while still being subject to bias towards the experimenters’ expectations. In the present study, we compare a response to many normative responses, to allow for a range of valid types of responses that are criterion-free. We establish a distribution of standard responses by collecting the natural language responses of a sample of unbiased viewers. In this distribution, some details will be mentioned by most viewers, whereas other details will be mentioned only by a minority of viewers. If a video modification, or an impairment of vision, leads to the acquisition of less information or to erroneous inferences, then the responses should be less similar to the response distribution from normally-sighted viewers for the same video clip, just as student papers that contain less correct knowledge will be scored lower using the comparison approach. When the normative dataset is sufficiently large, some concepts will be mentioned repeatedly, presumably because they are important, and this can be used to weight the scoring. Also, in a large normative dataset, less prominent features of the clip are more likely to be mentioned at least once, which gives a basis for recognizing these features in new responses and thereby avoiding penalizing less common responses.For the purpose of this scoring method, we collected a large set of free-recall descriptions of the video clips from normally-sighted individuals who came into the lab (lab-sourced). There were 60 lab-sourced participants, with equal numbers of men and women in three equally sized age groups: under 60 years old, 60–70 y, and greater than 70 y. They all had binocular visual acuity better than or equal to 20/30, no ocular conditions in their self-reported ophthalmic history, and healthy retinas (assessed using fundus photography). We selected 200 video clips of 30 s duration from Hollywood films and TV programs, representing the genres Cartoon, Documentary/Nature, and Drama/Other . Clips were presented with audio, but participants were instructed not to comment on it. Participants saw 40 clips each, leading to 2,400 responses in total, or 12 responses per video clip across all 60 participants. On completion of each video clip, the subject saw two prompts, “Describe this movie clip in a few sentences, as if to someone who has not seen it” and “Is there any other detail you want to mention?” The audio recordings of the two responses were concatenated to make a single response per video per participant. The responses were automatically transcribed using the speech recognition program MacSpeech Scribe . We pilot tested the built-in speech recognition function of the Apple iPad 2  for this purpose, but found it to be too limited both in its accuracy and its 90 s maximum recording time. These transcriptions were then corrected by workers on Amazon Mechanical Turk, 112 individuals in all, who listened to the audio and edited the text to match it. Although spot inspection suggested that the accuracy of spelling was high for these transcript editors, there were still occasional mistakes, such as confusing “dessert” and “desert”.N = 99) were not controlled. However, we did collect self-reported demographic information, and the reported median age was 35 y (range 20–66 y), with 63% of the workers female.As described in detail in Saunders, Bex and Woods We considered several algorithms for scoring the responses, all based on computing the similarity of responses to the normative responses to the same video clip, such that greater similarity corresponded to a better score. The evaluation used a take-one-out procedure: for each response in the normative dataset, we removed it from the dataset , and scored it based on the remaining dataset  as if it were a new response. These scores were used to classify the video clip from which the response originated, by determining which of the 200 clips had the highest average similarity between the new response and all the responses to that clip in the normative database. We then compared text-based similarity algorithms using the resulting percent correctly classified.The text passage similarity metrics we considered were derived from computational linguistics. In all cases, we first processed the text with the Text to Matrix Generator toolbox for MATLAB The second approach that we tried was a similar vector space model (VSM) of semantics Finally, for our fourth approach, we computed passage similarity by simply counting the number of words shared between two passages, after removal of stop words. Words that occurred more than once within a passage were only counted as a single match. Therefore, the score was the average of the vocabulary words shared with all the remaining responses to a video clip.The highest rate of correct classification, that is, matching responses to the video clip of origin, was the simple count of shared words, for both datasets . This reTherefore, in the subsequent results we report the scores obtained by averaging the number of non-repeating words that appeared in both the target response and each of the normative responses for the corresponding video clip, after removal of stop words. If the same word appeared in many normative responses, it was effectively weighted more heavily, whereas multiple occurrences of the same word within a normative response did not affect the score.n responses for each video and recomputing the percent of responses that were correctly classified according to their originating video clip, again using a take-one-out strategy and the shared word scoring method (relative to the corresponding dataset). We repeated the randomization procedure 100 times for each value of n, with n ranging between 2 and the full number of responses available. n. We fitted a two-parameter exponential function from which we determined the n at which the function reached 99% of its asymptotic value. The classification rate reached 99% of the asymptote at n = 7.9 for the crowdsourced dataset, and at n = 11.5 for the lab-sourced dataset.Would a smaller normative dataset be as effective? We computed the percent correctly classified for normative datasets with fewer than 12 responses per video clip (20 in the case of the crowdsourced dataset), by randomly sampling As another way to evaluate algorithm performance with smaller normative datasets, the error in the score of a particular response using a particular random subset was estimated as the difference between the computed score and the score with the full normative dataset. We conducted an experiment to validate the average shared word score as a measure of information acquisition. To assess a dose response effect, participants wore defocus lenses of different powers to induce optical blur, while they viewed a subset of video clips and gave responses as in the normative data collection. We hypothesized that lower levels of visual acuity, induced by the defocus lenses, would produce lower shared word scores.This research was approved by the Massachusetts Eye and Ear Infirmary Human Subjects Committee. All participants in the experiment, and the normative dataset collection, gave informed, explicit consent (either with a signature or by clicking a box on a Web form).We recruited 15 participants from the community with a median age of 34 y (21 to 67 y). They all had binocular visual acuity better than or equal to 20/20, no ocular conditions in their self-reported ophthalmic history, and healthy retinas. Participants had not contributed to the normative dataset, and so had not viewed the video clips previously. Using a visual acuity chart, we selected spherical defocus lenses for each participant that produced visual acuities of 20/20 or better, 20/50, 20/125, 20/320, and 20/800.We selected 20 clips for testing from the set of 200 that were used in collecting the normative dataset, with each genre represented proportionally . Each participant viewed all 20 clips in random order, with audio included, looking through defocus lenses that were switched in random order between each trial, for a total of 4 trials per visual acuity condition per participant. Participants received the same two prompts asking for a description of the movie as in the normative data collection, and their verbal responses were transcribed in the same manner using MacSpeech Scribe and Mechanical Turk workers.Responses were scored by counting the average number of words in common with the 12 responses for the originating video in the lab-sourced normative dataset. We used a mixed-model analysis p<0.001. Comparing all conditions to the 20/20 acuity condition, the 20/800 condition produced a significantly lower average score, p<0.001, and so did the 20/320 condition, p = 0.007. The shared word scores in the other acuity conditions were not significantly different from the 20/20 condition. There was also a significant decrease in mean score between the 20/50 condition and the 20/320 condition, p = 0.012. As another test of the dose response effect, the trend for a reduction in shared words as visual acuity reduced was significant , even when not correcting for video clip or participant differences.The shared word measure was therefore capable of detecting an effect of lowered visual acuity with 60 responses per acuity condition. Impairing vision with defocus lenses significantly reduced the amount of information that the viewer could access in the video clips. This demonstration provides support for the proposal that shared word scores from natural-language descriptions are a valid and reliable measure of information acquisition from a video clip.In this paper, we describe a novel approach to evaluating information acquisition, that does not rely on subjective judgments or manual coding of responses, and apply it to watching TV and movies for recreation. Since the scoring is objective, it is not vulnerable to experimenter bias. While the process of information acquisition from video is complicated, involving many stages of cognitive and perceptual function, when there is less information from the image available, as in the defocus experiment, less information can be acquired. Therefore declining scores for the natural-language descriptions associated with lower acuity is a necessary outcome for any valid measure of information acquisition.This method requires a substantial normative dataset, consisting of multiple natural-language descriptions of each stimulus, with, ideally, a large number of stimuli that should represent different characteristics of the stimuli of interest. We showed previously that crowdsourcing using Mechanical Turk is an efficient and low cost way to collect such a natural-language dataset, with properties similar to those of a dataset collected under more controlled conditions in the lab The concept of measuring information acquisition through free recall has applications outside of video viewing and reading comprehension. For example, a similar protocol could be used to test information acquisition from auditory stimuli, which could then be used to identify differences in hearing ability, or to evaluate sound compression algorithms. The measure could also suggest the presence of aphasias or other forms of disfluency in speech or writing, when standard vision test scores are within the normal range. Alternatively, if both speech and low-level vision are normal, a low score could suggest cognitive impairments, such as those resulting from traumatic brain injury or Alzheimer’s disease. A deficit in any of the stages of processing from the eye to the natural-language response would lower the score, and the contribution of other standardized tests could isolate which stage, or combination of stages, is causing the poor performance.Improvements to the automatic scoring algorithm could increase the method’s sensitivity. In the present study, it could not detect the smallest differences in visual acuity, for example between 20/20 and 20/50, with the sample size that was used. It seems that at 20/50, most of the salient and frequently-mentioned details of a video clip were still acquired. Therefore, there are limitations to the sensitivity of the method in its present form for monitoring and diagnosis of perceptual and cognitive problems in individuals. It is possible that the inclusion of audio may have reduced the sensitivity of the method to changes in visual acuity, even though participants were instructed to ignore the sound track. Another obstacle to interpreting scores for individuals is the possibility of subjects who use a distinctive vocabulary, or interpret the video clip in an idiosyncratic manner. These scores will be systematically lower due to divergence of their responses from the normative responses. The same problem affects groups of subjects who are not native speakers of the language of the normative dataset. However, although we evaluated several of the more popular algorithms for passage similarity and found them less effective than a simple count of shared words, more sophisticated algorithms for comparing responses to the normative dataset may be able to better detect individual differences in vision or video quality. In any case, we have demonstrated via the defocus experiment that even the simplest word matching method can detect differences due to within-subject experimental manipulations. Therefore, it can also be used to assess treatment effectiveness within individuals, and to track the progression or remediation of a condition.Organisms with healthy vision and an unimpaired view of their environment can extract a wealth of information about it, starting from raw sensory input. We have presented a novel method for quantitatively assessing this general information acquisition in humans, that is objective and requires relatively few experimenter resources.


High levels of alcohol consumption and increases in heavy episodic drinking (binge drinking) are a growing public concern, due to their association with increased risk of personal and societal harm. Alcohol consumption has been shown to be sensitive to factors such as price and availability. The aim of this study was to explore the influence of glass shape on the rate of consumption of alcoholic and non-alcoholic beverages.n = 159) attended two experimental sessions, and were randomised to drink either lager or a soft drink from either a curved or straight-sided glass, and complete a computerised task identifying perceived midpoint of the two glasses . Ethical approval was granted by the Faculty of Science Research Ethics Committee at the University of Bristol. The primary outcome measures were total drinking time of an alcoholic or non-alcoholic beverage, and perceptual judgement of the half-way point of a straight and curved glass.This was an experimental design with beverage , glass  and quantity  as between-subjects factors. Social male and female alcohol consumers (Participants were 60% slower to consume an alcoholic beverage from a straight glass compared to a curved glass. This effect was only observed for a full glass and not a half-full glass, and was not observed for a non-alcoholic beverage. Participants also misjudged the half-way point of a curved glass to a greater degree than that of a straight glass, and there was a trend towards a positive association between the degree of error and total drinking time.Glass shape appears to influence the rate of drinking of alcoholic beverages. This may represent a modifiable target for public health interventions. Alcohol consumption is associated with increased mortality and morbidity, with approximately 4% of the global burden of disease attributable to alcohol use Alcohol consumption is known to be sensitive to factors such as price, with price elasticities  in the United Kingdom estimated as −0.48 for beer consumed on premises, meaning that a price increase of 10%  would result in a decrease in consumption of 4.8% There may be other potentially modifiable factors which may influence alcohol consumption and drinking rate. These might include marketing signals , and vehicles for these signals such as the glasses from which beverages are consumed. Legislation to control or limit these signals may therefore influence drinking behaviour. A parallel can be drawn with the tobacco control literature, where plain packaging has been shown to increase visual attention towards health warnings compared with branded packaging in non-smokers and light smokers In particular, there has been an increase in branded drinking glasses in the United Kingdom in recent years, many of which include shape as a differentiating feature. These glasses include chalice glasses, curved beer flutes, tankard and novel curved beer glasses, and have been used by numerous alcohol brands including Stella Artois, Heineken, Guinness, Pilsner, Amstel, Smirnoff, Carlsberg, Carling and Jameson's whiskey. While alcohol advertising is still permitted in the United Kingdom, packaging and, by extension, drinking glasses provide another, currently unregulated, marketing channel.As well as presenting overt branding information, these glasses may influence drinking rate by disguising the volume of beverage remaining. Anecdotally, this is particularly the case in curved glasses where the majority of the volume is contained in the upper portion of the glass. There is also empirical research to support an influence of object shape on volume perception To date there has been no research investigating the effect of glass shape on drinking behaviour. We therefore explored whether glass shape modifies the time taken to consume alcoholic and non-alcoholic beverages. We hypothesised that glass shapes where it is more difficult to accurately judge when half the beverage has been consumed would be associated with faster rates of drinking, compared with glass shapes where it is easier to make an accurate judgement.Ethical approval was granted by the Faculty of Science Research Ethics Committee at the University of Bristol and the study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants.Participants were allocated to one of eight groups using a factorial design in which they were asked to drink either 6 fl oz or 12 fl oz of either an alcoholic (lager) or a non-alcoholic (carbonated soft drink) beverage, from either a straight or curved 12 fl oz glass. Group allocation was randomised with the constraint that groups contained equal numbers of male and female participants. The experimental design therefore comprised three between-subjects factors of beverage , glass  and quantity .Participants attended two experimental sessions approximately one week apart. At one session participants were presented with a beverage and asked to consume this at their own pace whilst watching a nature documentary. These sessions were videotaped for subsequent analysis of consumptive behaviour. When they had finished the beverage, participants were given a wordsearch task that was included to disguise the aim of the study. During the other experimental session, participants completed a computer task designed to measure perceptual judgement of the fullness of each glass. A filler paper and pen task was included in order to further disguise the true nature of the study. Session order was randomised.One hundred and sixty  social alcohol drinkers  of ordinary strength (3.5–4% ABV) beer, a small glass (125 ml) of 8% ABV of wine or a single measure (25 ml) of a 40% ABV spirit) were recruited from the staff and students of the University of Bristol and from the general population by means of poster and flyer advertisements, and word-of-mouth. Participants were required to be in good psychological and physical health, aged between 18 and 40 years, and not currently taking any psychiatric medication. Exclusion criteria included current use of illicit substances (excluding cannabis) and a direct family history of alcoholism (defined as parent and/or sibling) and not liking lager or lemonade. Eligibility was ascertained on these variables by self-report, i.e., participants were required to provide “Yes” or “No” responses to questions regarding their physical/psychiatric health, family history of alcoholism and current drinking quantities and preferences. Participants were asked to abstain from alcohol consumption for 12 hours prior to each test session, and were only enrolled onto the study if they provided a zero breath alcohol reading at the start of the session. Participants were paid £10 or awarded course credit, as appropriate, at the end of the study.The two glasses were of equal volume (12 fl oz) and were both of a type frequently used to consume soft drinks and beer. One glass was straight-sided with an unambiguous midpoint . The other glass was a curved flute-style glass with an ambiguous midpoint  see . This glFor the computerised glass rating task, two sets of photographic stimuli were created using a digital camera . Each set was a sequence of 61 photographs ranging from an empty (0) to a full (60) glass with liquid added in 60 equal volume increments. To do this, the total volume of the glass was measured and divided by 60. The photographs were converted to greyscale images (1024×768 pixels). Two interleaved 1-up 1-down staircases The drinking session was recorded using a video camera (Hitachi Hybrid Camcorder DZHS500E). An independent researcher blind to the study hypotheses scored the video recordings of drinking behaviour, using a specifically-designed DOS program that involved pressing “1” each time a sip was initiated (defined as liquid touching lips) and “2” when the sip ended (defined as liquid leaving lips) To disguise the aim of the study, a filler task was included, where participants were asked to rate alcoholic and non-alcoholic beverages and branded bottles for likeability and alcohol-relatedness. The nature of the study was further disguised by inclusion of a 4-minute pen and paper wordsearch task, following consumption of the beverage. These data were not analysed.The questionnaire measures comprised the Alcohol Use Disorders Identification Test (AUDIT) Experimental sessions lasted approximately 20 minutes and all testing took place between 12:00 and 18:00 hours. Upon arrival at their first session, participants were given an opportunity to read the information sheet and ask questions before providing written informed consent. Participants were told that the study examined the effects of alcohol consumption on wordsearch performance, in order to disguise the nature of the primary outcome measure of rate and pattern of drinking, which may have affected natural drinking behaviour. Participants were screened to ensure that they met the inclusion criteria, and provided a breath sample to ensure that they had complied with the alcohol abstinence requirement .For the drinking session, participants were randomised to receive either 6 fl oz  or 12 fl oz  of lager at 4% alcohol by volume  or soft drink . All beverages were chilled prior to serving and were opened and poured immediately prior to consumption in order to ensure that carbonation was consistent across participants. Baseline ratings included self-report measures of alcohol use and craving . Participants were then given their beverage and were told that they should consume all of it at their own pace whilst watching a nature documentary . A sequence of the footage was pre-selected that was considered not to contain emotive material. The experimenter started the videotape and left the room. When participants had finished their beverage, the experimenter returned and presented participants with a wordsearch task in which they were instructed to find as many words as possible in four minutes. Upon completion of this task, measures of alcohol craving (AUQ) were taken again.For the computer session, the order of the computer tasks  was randomised. The straight and curved glass conditions of the computer tasks were presented in separate blocks. Between these blocks the picture-rating filler task was completed. At the end of the final session participants were informed that debriefing information would follow via email at the end of the study.Data were analysed using a 2×2×2 ANOVA with beverage , glass  and quantity  as between-subjects factors. For the analysis of AUQ data an additional within-subjects factor of time  was included. Where significant interactions were observed, simple effects ANOVAs or t-tests (two tailed) were used as appropriate. Finally, to examine the association between drinking rate and perceptual bias, a Pearson's correlation analysis was conducted on the degree of perceptual bias of curved glass  and the primary outcome measure of total drinking time. An alpha level of 0.05 was retained throughout.n = 159; 80 male) were on average aged 23 years , weighed 71 kg , and had an AUDIT score of 11 . A series of 2×2×2 ANOVAs with beverage , glass  and quantity  as between-subjects factors indicated no significant differences between groups on these measures (ps>0.13). Characteristics of participants are summarised in Data from one participant who was unable to finish the beverage were excluded. Participants  indicated that for both straight  and curved  glasses the half-way point was perceived to be below the true half-way point. A paired-sample t-test indicated a significant difference between the two glass conditions , indicating that the halfway-point was perceived to be below the true half-way point to a greater degree for the curved glass compared to the straight glass.One-sample F  = 4.80, p = 0.030, partial η2 = .03), reflecting an increase in craving over time, and beverage , reflecting greater craving in the lager group. These were qualified by a time × beverage interaction , indicating that this increase in craving over time occurred in the lager condition but not in the soft drink condition. There was also a main effect of quantity , reflecting higher craving in the 6 fl oz condition, but this was not qualified by interactions with time or beverage and therefore not considered further. There was no evidence for other main or interaction effects (ps>0.23).A 2×2×2×2 ANOVA of AUQ data, with time  as a within-subjects factor and beverage , glass  and quantity  as between-subjects factors, indicated a main effect of time , reflecting longer drinking time in the lager condition, glass , reflecting longer drinking time in the straight condition, and quantity , reflecting shorter drinking time in the 6 fl oz condition. These were qualified by a beverage × glass × quantity interaction .A 2×2×2 ANOVA of total drink time, with beverage , glass  and quantity  as between-subjects factors, indicated main effects of beverage , but not the 6 fl oz condition . Further stratified analyses indicated that total drinking time for 12 oz of lager was longer when consumed from a straight glass compared to a curved glass (t (37) = 2.83, p = 0.007, d = 0.93), but did not differ by glass condition for 12 oz of soft drink (t (38) = 0.29, p = 0.78, d = 0.09). Including change in subjective craving as a covariate did not alter these results. These data are presented in To explore the beverage × glass × quantity interaction further, analyses were stratified by quantity. These indicated a beverage × glass interaction effect in the 12 fl oz condition  and total interval duration  reflecting more sips and longer time between sips in the straight versus curved glass condition. There were main effects of quantity for total number of sips , total sip duration  and total interval duration  reflecting more sips and longer total sip and interval durations in the full versus half full condition. There was also a main effect of beverage for total interval duration  with longer interval durations in the alcohol vs. placebo condition. There was a beverage × glass × quantity interaction for total interval duration , which was explored further in analyses stratified by quantity. These indicated a beverage × glass interaction effect in the 12 fl oz condition , but not the 6 fl oz condition . Further stratified analyses indicated that total interval time for 12 fl oz of lager was longer when consumed from a straight glass compared to a curved glass (t = (37) 2.81, p = 0.008, d = 0.92), but did not differ by glass condition for 12 fl oz of soft drink (t (38) = 0.22, p = 0.83, d = 0.07).To investigate the nature of this effect on drinking behaviour, additional 2×2×2 ANOVAs of total number of sips, total sip duration, total interval duration were conducted. There were main effects of glass for total number of sips (r(156) = .15, p = .059.Three participants with outlier bias scores (ascertained using boxplots) were excluded from the analysis. There was a trend towards a significant positive correlation between total drinking time and perceptual bias to the curved glass, Pearson's p<.001, indicating a high level of inter-rater reliability.The ratings of the two independent raters were strongly and positively correlated, single measures intraclass correlation (31) = .98, Previous research has demonstrated differences in pouring practices depending on the glass shape. However, our study is the first to examine whether glass shape directly influences drinking behavior. Our data indicate that the shape of a drinking glass influences the rate of drinking of an alcoholic beverage, but not a non-alcoholic beverage. Specifically, alcoholic beverages were consumed more slowly from a straight glass than a curved glass when a full glass was presented. This effect was not observed when a half glass was presented, and was not observed for soft drinks. Moreover, participants under-estimated the true half-way point of a curved glass to a greater degree than a straight glass, and the degree of this bias was modestly associated with drinking rate (non-significant trend). This supports our initial hypothesis that glass shapes which induce a perceptual bias in the judgement of the half-way point in the glass will be associated with more rapid drinking. Additional analyses of topographical variables suggested that the slower drinking rate observed when consuming alcohol from a full, straight glass was due to more time spent between sips rather than due to differences in the number of sips or length of sips. These effects do not appear to be driven by differences in urges to drink alcohol, as the effect did not differ when change in AUQ scores were included as a covariate.One possible mechanism for the effects we observed is that individuals may titrate their drinking rate based in part on perceptual judgements. That is, if they wish to consume a beverage in a certain time, they may titrate their drinking to reach the half-way point in the glass after half this time has elapsed. However, if their perceptual judgement of the half-way point is lower than the real value, they will have in fact consumed more than half of the beverage by this point . Perceived consumption will affect subsequent drinking behaviour, as individuals who perceive that they have drunk little will compensate with an increase in consumption volume and/or rate This does not explain why we observed this effect for alcoholic beverages but not non-alcoholic beverages. It may simply be that perceptual judgements play a greater role in influencing drinking rate for alcoholic beverages than for non-alcoholic beverages. It is known that dietary preferences are learned over time and become established, such that visual cues come to dominate food choice and portion size selection An alternative explanation is that the curved glass may have elicited alcohol-related conditioned responses and/or expectancies that influenced drinking behaviour. The curved glass is particularly associated with the consumption of lager beverages and this may have provided an additional cue that motivated alcohol consumption. The appetitive motivational model suggests that drug-related cues can elicit appetitive responses and positive affect, which in turn increase approach and consumptive behaviours. This is somewhat undermined by the fact the straight-sided glass is also commonly used to serve alcohol . It can be argued however that the straight glass may be associated with the consumption of many different types of drink, including non-alcoholic drinks, and therefore the explicit association between the straight-sided glass and alcohol is weaker. This premise is merely speculative and further research is required to clarify the mechanism underlying the findings. These results have potential public health implications. A number of factors which might influence this have been considered, such as opening hours and the availability of low-cost alcohol In conclusion, our data indicate that glass shape influences the rate of consumption of alcoholic beverages, possibly due to differences in the perceptual judgement of the half-way point of the glass across different glass shapes, although further research is required to examine the mechanisms underlying this effect. This, in turn, may influence pre-consumption decisions regarding the appropriate drinking rate necessary to titrate consumption as desired. While our study cannot fully resolve the mechanism which underlies the effects we observed, these findings have the potential to inform policy decisions regarding structural changes to the drinking environment which may reduce drinking rates and correspondingly impact on resulting alcohol-related harms.


Background: Previous review studies have suggested that computer games can serve as an alternative or additional form of treatment in several areas . Although several naturalistic studies have been conducted showing the usefulness of serious video games in the treatment of some abnormal behaviours, there is a lack of serious games specially designed for treating mental disorders.Aim: The purpose of our project was to develop and evaluate a serious video game designed to remediate attitudinal, behavioural and emotional processes of patients with impulse-related disorders.Method and results: The video game was created and developed within the European research project PlayMancer. It aims to prove potential capacity to change underlying attitudinal, behavioural and emotional processes of patients with impulse-related disorders. New interaction modes were provided by newly developed components, such as emotion recognition from speech, face and physiological reactions, while specific impulsive reactions were elicited. The video game uses biofeedback for helping patients to learn relaxation skills, acquire better self-control strategies and develop new emotional regulation strategies. In this article, we present a description of the video game used, rationale, user requirements, usability and preliminary data, in several mental disorders. Increasingly, more health professionals are becoming interested in innovative and cost-effective treatment approaches. Due to this reason, new technologies for treatment and therapeutic support of various medical illnesses are being commonly developed and applied, from Internet to video games .Video games, a special form of new technologies, were initially developed for entertainment. However, during the last few years, the use of serious games for educational purposes  and traiGiven the increasing interest of many national health care systems in extending the accessibility of services and treatment programmes for mental disorders, several new technological strategies have been used, from telemedicine to Internet approaches, vodcast and virtual reality scenarios . To dateAlthough several naturalistic studies have been conducted showing the usefulness of serious video games for enhancing some positive attitudes , increasPlayMancer is an EU initiative to develop a video game prototype for treating specific mental disorders (namely EDs and impulse control disorders). It is being applied at the Department of Psychiatry  in mental disorders  and introduces the player to an interactive scenario (named Islands), where the final goal is to increase emotional self-control skills in patients and self-control over their general impulsive behaviours. A multidisciplinary team of clinicians, engineers and programmers have developed this video game, by considering user requirements and emotional reactions as well as personality profiles of the targeted patients.Within severe impulse-related disorders, shared dysfunctional emotional regulatory processes and disinhibited personality traits  are amonThe scenario which we call “Islands” is based on the idea that the patient is on an island that forms part of several islands in an archipelago. On each island, different activities are available. The activities are linked to varying difficulty levels of game tasks. In this adventure game, the player is confronted with several challenges and situations in order to improve the skills and attitudes that we are trying to change  see . As the mini-games are developed:The game consists of a series of specifically designed tasks . Therefore, three prototyped The face of Cronos: A game in which the player plans a climbing path up a cliff, while administering his/her resources and avoiding obstacles, produced by emotions.Treasures of the sea: A game in which the player swims under water, gathering artifacts and balloon fish. The player also has to administer and maintain his/her oxygen level in order to keep on playing. The difficulty of the diving is controlled by the player's current emotions.Sign of the Magupta: A relaxation game in which a constellation of stars is drawn up corresponding to the level of calmness of the player  feature extraction algorithms. The bio-signal, facial  and the speech based emotion recognition  and HR variation, skin temperature, breathing frequency), measured by a stationary measurement system based on the ognition , 2010b pIn mental disorders (in this case EDs and impulse control disorders), controlled prospective longitudinal studies have been conducted since September 2010, at the Department of Psychiatry . The Islands video game is used as an additional therapeutic tool , with consecutively admitted outpatients. To avoid video game side effects , the whoEach session consists of exposure to the above-mentioned video game, where the performance of patients is collected for 20 min. Before and after each video game, 3-min of relaxing music is provided to the experimental subjects. Each session is carried out once a week, coinciding with the day that the patients come to the traditional therapy. According to the length of the traditional therapy, 12–14 weekly sessions of video game are applied.The inclusion criteria used for the whole project study were a diagnosis of bulimia nervosa, binge ED or pathological gambling, according to DSM-IV criteria , and an To analyse the usability and comfort when using the Video game and the connected multiple biosensors and recording camera-microphone, the system usability scale SUS;  was compvs. 48.6% , and the mean age was 32.3 years old (SD 9.3), ranging from 18 to 49; 46.3% of the individuals were non-married and 65.5% had secondary or university studies. As shown in p = 0.922) on average SUS scores.Between May and June 2010, we conducted a pilot test study with 24 patients ) and 14 healthy controls-comparison group who volunteered to participate in the study, and who signed an informed consent to participate. All of them were screened for video game and Internet addiction, but also for general health state. The gender proportion for the whole sample was 51.8%  Although new technological approaches have increasingly been used as therapy for mental disorders, there is a lack in the literature regarding use of video games and controlled studies analysing its effectiveness. The few studies attempting to analyse video games, as combined therapy in mental disorders, are simply descriptions of series of cases or naturalistic studies with important methodological limitations. However, the internal features of this type of technologies may encourage clinicians and technicians to continue investigating this field.Taking into account our clinical experience using and developing video games, the most important lessons that we have learned are the following: (a) the acceptance of mental disorder patients is very high for participating and using video games; (b) this approach is a good platform to work out underlying attitudinal and emotional problems, that otherwise are difficult to treat in mental disorders , in an intensive and motivating way; (c) internal characteristics of video games make it feasible to apply techniques that tend to be difficult to apply in those patients, such as controlled intensive exposure, immediate positive and negative reinforcing, complex biofeedback approach, and real time monitoring of physiological-emotional reactions.Currently the PlayMancer evaluation trials are still ongoing, but initial results, based on more than 40 mental disorder outpatients, seem to indicate that: (a) ED and impulse control disorder patients feel comfortable using such a video game (usability over 85%); (b) a source of stress (such as specific parts of Islands) is able to trigger high physiological and emotional reactions in mental disorder patients, and is moreover over expressed when compared with healthy controls; (c) negative and positive emotions  are positively linked with higher physiological reactivity in mental disorders; (d) as shown in other studies , relaxatLooking at the short-term effects, after using this video game strategy, the patients started to show new coping styles with negative emotions in normal stress life situations, additional generalization patterns and more self-control strategies when confronted with them. As shown in previous studies , working


The World Health Organization has called for an effort to eliminate Lymphatic Filariasis (LF) around the world. In regions where the disease is endemic, local production and distribution of medicated salt dosed with diethylcarbamazine (DEC) has been an effective method for eradicating LF. A partner of the Notre Dame Haiti program, Group SPES in Port-au-Prince, Haiti, produces a medicated salt called Bon Sel. Coarse salt is pre-washed and sprayed with a solution of DEC citrate and potassium iodate. Iodine levels are routinely monitored on site by a titrimetric method. However, the factory had no method for monitoring DEC. Critical analytical issues include 1) determining whether the amount of DEC in each lot of Bon Sel is within safe and therapeutically useful limits, 2) monitoring variability within and between production runs, and 3) determining the effect of a common local practice  on the availability of DEC. This paper describes a novel titrimetric method for analysis of DEC citrate in medicated salt. The analysis needs no electrical power and requires only a balance, volumetric glassware, and burets that most salt production programs have on hand for monitoring iodine levels. The staff of the factory used this analysis method on site to detect underloading of DEC on the salt by their sprayer and to test a process change that fixed the problem. As researchers develop more sophisticated technologies, parts of the world are left behind. The front lines of fighting many diseases lie in regions where expensive technology is not feasible. As part of the effort to eradicate lymphatic filariasis in Haiti, our group's goal was to design an assay that would allow a chemist, with basic equipment, to quantify the levels of diethylcarbamazine citrate on medicated salt. With access to university research facilities, we were able to devise and test a back-titration procedure that can measure the medication levels with sufficient accuracy and precision. Our method capitalized on the fact that the medication is acidic. This characteristic allows us to combine an unknown, medicated salt sample with a known quantity of base and then back-titrate with acid to determine diethylcarbamazine citrate concentration based on the neutralization point. Developing this protocol has put the power of quality control into the hands of the Haitian factory producing the medicated salt. With the ability to better monitor dosing levels, we have increased the effectiveness of this program in Haiti. Using modern research facilities to produce effective, low-tech methods could be a useful approach for tackling many worldwide medical and environmental issues. Wuchereria bancrofti) is the cause of 90% of lymphatic filariasis cases globally. Mosquito bites transmit larval nematodes (microfilariae) present in the blood stream of infected persons, and although the adult nematodes are resistant to medical treatment, human transmission in endemic regions can be stopped by administering drugs, such as diethylcarbamazine (DEC), that kill the microfilariae. DEC has had a long history of safe use in mass drug administration (MDA) LF eradication programs, W. bancrofti do not appear to have developed resistance to DEC. The World Health Organization has called for an effort to eliminate Lymphatic Filariasis (LF) around the world. A partner of the Notre Dame Haiti program, Group SPES in Port-au-Prince, Haiti, produces a double-supplemented salt called “Bon Sel”. The “gold standard” assay for DEC citrate uses high-performance liquid chromatography (HPLC). Samples of untreated NaCl and pharmaceutical grade DEC citrate (EPICO) were obtained from the Bon Sel plant in Haiti; pure DEC citrate for HPLC standardization was obtained from Sigma-Aldrich. The untreated NaCl was a coarse grade produced by evaporation of seawater and had visible contaminants .2. A 0.200 M NaOH stock solution should be prepared (it is stable for at least 4 weeks) and diluted each day to give the working 0.0100 M NaOH solution. Phenolphthalein indicator solution was prepared by dissolving 0.5 g of phenolphthalein (Aldrich) in 500 mL of a 50% ethanol:water solution.0.0040 M HCl was prepared by sequential volumetric dilution of concentrated HCl, and stored in a plastic bottle. Dilute NaOH solutions are unstable due to reaction with atmospheric COStandards: DEC citrate standards  are prepared in the same matrix as the medicated salt samples. The final solutions are 10% w/v in salt, thus, to prepare the 0.50% standard, 10 g NaCl and 0.0500 g DEC citrate are mixed with DI water to give a final volume of 100 ml.Samples: 5.00 g of medicated salt is dissolved in deionized or distilled water to a final volume of 50.00 ml with vigorous shaking . A small amount of insoluble residue is usually present in these samples.2O : 3.66 ; 3.42 ; 3.16 , 3.10 ; 3.07 ; 2.825 ; 2.81 ; 2.67 ; 1.02 . The citrate methylene peaks overlapped the N-CH3 group on the DEC, so this spectrum was not used to calculate the citrate:DEC stoichiometry. DEC citrate in DMSO : ∼10.5 ; 3.17; 3.11 , 2.75; 2.63 ; 2.59 ; 2.49 ; 1.03 .DEC citrate in DA 10.00 ml aliquot of the solution to be analyzed is mixed with 10.00 ml of 0.0100 M NaOH and two drops of phenolphthalein indicator are added to give a uniform pink color. The solution is titrated to a clear endpoint with 0.00400 M HCl. The titration should be carried out in triplicate and the results averaged; the relative standard deviation of the endpoint volumes for a triplicate trial 2PO4 adjusted to pH 3.2 with H2SO4 or H3PO4) and 1 part acetonitrile. The eluent was degassed by vacuum filtration through a 0.4 micron ceramic filter. The detector wavelength was set at 210 nm and a 20 µl sample loop was used. DEC citrate elutes at approximately 5.6 minutes.Samples were analyzed using Mathew's method Samples and standards prepared for back titration are approximately 10% salinity, with 100 mg/ml NaCl, which would clog the HPLC column. These samples were diluted 10X and filtered on a Whatman GD/X 0.45 µm PES syringe filter before injection onto the HPLC column. Using this sample preparation protocol, a standard salt sample containing 0.25% w/w DEC, when prepared for analysis on the HPLC, contains 0.025 mg/ml DEC citrate and 10 mg/ml NaCl. Standards for HPLC analysis ranged from 0.005–0.200 mg/ml DEC citrate in 1.0% saline.2O and d6-DMSO at 400 MHz) to a sample of the DEC citrate (manufactured by EPICO) that is used at the Bon Sel factory in Haiti. The 1∶1 DEC∶citrate stoichiometry was confirmed by integration of the 1H-NMR peaks from the diastereotopic methylene groups on the citrate and the triplet from the ethyl groups on the DEC  From the DEC∶citrate stoichiometry, each equivalent of DEC citrate (see structure in 6.Standard DEC citrate used in this study (from Sigma-Aldrich) was identical by NMR .m is given by the least square fit to the slope of the calibration curve, and s is the standard deviation of 7 determinations of DEC concentration for the 0.050% standard sample. The LOD is 0.029% and the LOQ is 0.096% for the titration method.Titration of standard samples gave a linear calibration curve ; the lincalc is 0.35. This indicates that the difference between the titration and HPLC results was not statistically significant for samples at concentrations of 0.1%–0.8%, although the precision of the HPLC method was superior (RSD <5% for HPLC) and its LOQ was much lower.To compare the titration method and the HPLC method, multiple standards and unknowns were analyzed with both methods. Analysis of Bon Sel samples from seven production runs in mid-2009 showed that all seven production lots ranged from 0.09–0.13% DEC citrate, with an average of 0.10%±0.01%.  This shoTo monitor heterogeneity within the bags of Bon Sel, three 10 g grab samples from each of several 1 kg bags of Bon Sel (taken from different lots) were tested; the levels of DEC citrate varied from 0.08 to 0.15% for samples taken within the same bag of Bon Sel. This heterogeneity was not due to errors in the titration analysis, as the results were confirmed by HPLC analysis, which has a much higher precision. Because the DEC is sprayed onto the salt, which contains both coarse (low surface area) and fine (high surface area) crystals, DEC loading is expected to be a function of salt crystal size. Two lots of Bon Sel from the mid-2009 production runs were screened to separate particles >4 mm in size from particles <4 mm in size; in each case, the large crystals had significantly lower loading of DEC than the small crystals. For example, in one lot, the large crystals gave a DEC loading of 0.034±0.001% while the small crystals came in at 0.085±0.002% (these low loadings were measured using HPLC to obtain more precise results). The variation in loading with crystal size appears to be large enough to account for most of the heterogeneity in the within-lot analyses, and suggests that more uniform spray coating and higher loadings would be achieved by crushing the salt before spraying it.The salt available in Haitian markets is often of low purity, and many people rinse the salt before using it in cooking. Although Bon Sel is pre-washed and the packaging advises consumers not to wash the salt, habits can be hard to break, and some people probably still wash the Bon Sel. Tests on the effect of hand rinsing  showed retention of 40–50% of the DEC citrate and 60–70% of the iodate after the medicated salt was washed. This result suggests that a fortification level of 0.3–0.4% DEC citrate, at the high end of the recommended scale, would be likely to deliver therapeutically useful doses to consumers of the medicated salt regardless of whether or not they rinse it.A simple titration-based assay allows determination of diethylcarbamazine (DEC) citrate concentrations in medicated salt produced in Haiti for an anti-lymphatic filariasis program. The assay can be carried out with widely available equipment and materials and thus offers a useful tool for quality control and field analysis of DEC. The development of this method, which allows quantification of the medication, DEC citrate, has already proven useful for quality control in the Haiti plant where salt fortification takes place. Historically, identification and communication of flaws in the salt fortification levels have taken several months as samples were sent back to the US for analysis. Using the back titration analysis of DEC, chemists in Haiti can now identify variation in DEC loading as batches of Bon Sel are produced. This analysis will allow the Bon Sel plant to act more rapidly and independently in their effort to supply the area with properly medicated salt. An increased efficiency in Bon Sel production should bolster the endeavor to reduce and eventually eliminate lymphatic filariasis in Haiti.


The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is a three-item alcohol screening questionnaire where threshold scores of ≥4 for men and ≥3 for women have been associated with a higher risk of alcohol misuse. However, some response patterns yield inconsistencies: some individuals who report drinking within National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommended limits on the individual AUDIT-C screen positive based on the AUDIT-C score, and some who report exceeding drinking limits on the individual AUDIT-C screen negative based on the AUDIT-C score. The objective of this study was to determine the prevalence of discordant AUDIT-C screening results and reported drinking on the individual AUDIT-C questions among men and women who reported drinking alcohol in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)  and to discuss the implications of this discordance for brief interventions. Among men in the US population-based sample, 5.0% had negative screens despite reporting risky drinking, and 8.8% had positive screens while reporting drinking within recommended limits. Among women, 0.8% had negative screens despite report of risky drinking, and 17.4% had positive screens despite reporting drinking within recommended limits. Of those with negative screens, all individuals who exceeded drinking limits reported heavy episodic drinking on AUDIT-C question 3, suggesting that brief interventions for heavy episodic drinking can be offered to 5% of men and about 1% of women who do not screen positive on the AUDIT-C. Patients who screen positive on the AUDIT-C despite not reporting risky drinking can be advised explicitly about drinking limits and told that, although they are not reporting drinking above the recommended limits, some patients with similar scores develop problems due to drinking. Web-based screening and brief intervention programs offer an opportunity to provide appropriate and specific feedback to address discordant AUDIT-C response patterns.


Fundus photography in adults and cooperative children is possible with a fundus camera or by using a slit lamp-mounted digital camera. Retcam™or a video indirect ophthalmoscope is necessary for fundus imaging in infants and young children under anesthesia. Herein, a technique of converting and using a digital video camera into a video indirect ophthalmoscope for fundus imaging is described. This device will allow anyone with a hand-held video camera to obtain fundus images. Limitations of this technique involve a learning curve and inability to perform scleral depression. Photography of fundus pathology is often necessary for documentation, diagnostic and medicolegal purposes. Serial fundus photography helps assess response to treatment. Photographic documentation of fundus lesions is particularly essential in infants and children with diseases such as retinoblastoma.It is possible to obtain good fundus images for documentation in cooperative adults using the fundus camera as well as the slit lamp-mounted digital camera, although with some difficulty. It may bTechniques such as custom mounting the fundus camera vertically, hand-held fundus camera, video indirect ophthalmoscope and the Retcam™ have been employed to image the fundii of children under general anesthesia. Each tecA regular hand-held video camera with a flash mount may be used; higher resolution cameras will offer clearer pictures and videos. A thin torchlight with a bright focused light beam (pen torch) is used as the light source for illuminating the fundus. A home gas lighter holder made of plastic can be modified to slide in to the flash mount of the camera and the torch light is clipped on to the gas lighter holder Figs.  and 2. TThe technique used to image the fundus is similar to that of uniocular indirect ophthalmoscopy. The torchlight is turned on and focused on a wall at an arm’s length as one would focus the indirect ophthalmoscope – the beam illuminating the upper ½ of the liquid crystal display (LCD) screen.The infant to be examined is administered general anesthesia after pupillary dilatation; if an adult, he / she is made to sit/lie comfortably on the examination chair/couch after pupillary dilatation. Indirect ophthalmoscopy is performed as one would perform a binocular indirect ophthalmoscopy using a condensing lens held in the nondominant hand. The dominant hand is used to hold the hand-held video camera and, using the viewfinder of the hand-held video camera, the external eye is visualized by taking the condensing lens close to the eye . The conIn contrast to existing fundus imaging techniques, this technique makes use of equipment that is likely to be available with most ophthalmologists and does not require purchase of infrequently used equipment, such as the video indirect ophthalmoscope or the expensive Retcam™. Posterior pole photographs and video recording can be obtained in patients with clear media.As in indirect ophthalmoscopy, the light source can create reflexes on the anterior and posterior surfaces of the condensing lens. This can be negated to some extent by minimal tilting of the condensing lens. White balance of the hand-held video camera would also need adjustment to avoid overexposure when capturing an object that is focally illuminated against a dark background – the situation that exists during ophthalmoscopy. The alignment of the torchlight is critical and some hand-held video camera wherein the flash mount is distant from the objective lens may not be suitable for employing this technique. The torchlight should be as close as possible to the objective lens of the hand-held video camera. The auto-flash facility of the camera should be turned off when taking still photos of the fundus.There is a learning curve when one adjusts to performing uniocular indirect ophthalmoscopy, manipulating the hand-held video camera and the camera controls with one hand and the condensing lens with the other. Aligning the hand-held video camera and the condensing lens to the pupil will need some practice. Using the view finder of the hand-held video camera rather than the LCD screen would help achieve alignment faster as the eyepiece is in line with the objective while the LCD screen is offset from the line of the objective lens. Wearing presbyopic correction aids using the viewfinder to image the fundus. Scleral depression is not possible given that both hands are employed. Peripheral fundus examination is also difficult with troublesome reflexes from the lens and the limitations in focusing of the hand-held video camera.However, the advantages are least capital expenditure, capability to document fundus images of infants and children under general anesthesia and also the capability to perform a dynamic video indirect ophthalmoscopy in adults.


The HIV epidemic in Vietnam has from its start been concentrated among injecting drug users. Vietnam instituted the 2006 HIV/AIDS Law which includes comprehensive harm reduction measures, but these are unevenly accepted and inadequately implemented. Ward police are a major determinant of risk for IDUs, required to participate in drug control practices  which impede support for harm reduction. We studied influences on ward level police regarding harm reduction in Hanoi to learn how to better target education and structural change.After document review, we interviewed informants from government, NGOs, INGOs, multilateral agencies, and police, using semi-structured guides. Topics covered included perceptions of harm reduction and the police role in drug law enforcement, and harm reduction training and advocacy among police.Police perceive conflicting responsibilities, but overwhelmingly see their responsibility as enforcing drug laws, identifying and knowing drug users, and selecting those for compulsory detention. Harm reduction training was very patchy, ward police not being seen as important to it; and understanding of harm reduction was limited, tending to reflect drug control priorities. Justification for methadone was as much crime prevention as HIV prevention.Competing pressures on ward police create much anxiety, with performance measures based around drug control; recourse to detention resolves competing pressures more safely. There is much recognition of the importance of discretion, and much use of it to maintain good social order. Policy dissemination approaches within the law enforcement sector were inconsistent, with little communication about harm reduction programs or approaches, and an unfounded assumption that training at senior levels would naturally reach to the street.Ward police have not been systematically included in harm reduction advocacy or training strategies to support or operationalise legalised harm reduction interventions. The practices of street police challenge harm reduction policies, entirely understandably given the competing pressures on them. For harm reduction to be effective in Vietnam, it is essential that the ambiguities and contradictions between laws to control HIV and to control drugs be resolved for the street-level police. Where there is injecting drug use (IDU), there is risk of transmission of blood-borne viruses (BBV), including HIV and hepatitis B and C (HBV/HCV). Comprehensive harm reduction approaches have been convincingly shown to diminish this risk and to prevent BBV transmission. After the first HIV case was reported in Vietnam in 1990, the number of reported HIV infections grew rapidly in all provinces . In 2009Law on HIV/AIDS Prevention and Control of victims… (Article 9.6)· …protect the scenes [of crimes]… (Article 9.6)· …make initial records, take testimonies of victims and witnesses (Article 9.6)· …to seize and preserve material evidences… (Article 9.6); and,· To sanction administrative violations; make dossiers proposing the application of other administrative sanctions against violators… (Article 9.8).· According to one Ward Police Chief, “Drugs are only a portion of our work. We deal with terrorism, traffic, fraud, robbery, counterfeit money and fake products.” Another Ward Police Officer described his roles this way:The main one is to learn by heart the [identity and circumstances of the] 2000 people [in the ward]; second, to go to their houses and learn about updates, what is happening. Also we must compile profiles on the businesses, companies and shops … Also, do some analysis of [our local statistics] and give it to the district level. Sometimes we are messengers, giving out district level information to the local people, sometimes trying to do fundraising for poor people to raise money, such as for people affected by the floods. Sometimes there will be a campaign to vaccinate the dogs and cats for rabies or diseases. On the night shift sometimes we have to go out to deal with fighting between husbands and wives. With the introduction of harm reduction interventions in Vietnam, the role of ward police in maintaining drug user profiles – which form the basis of decisions about compulsory residence in 06 centres – conflicts with their harm reduction implementation responsibilities as stipulated in Decree 108 , which rWhilst there has been no systematic approach to harm reduction training for ward police, they have been trained in some locations through programs supported by international agencies. Several police interviewees at the ward and district level said that the ward police were important to harm reduction but they were rarely, if ever, the target of training or advocacy to garner their support for harm reduction approaches.There are no classes or no training about this at the Police College. I just heard about the programs. I haven’t been trained. I learned from mass media, and other ward police haven’t been given any training. Some police interviewees indicated that while familiar with the term ‘harm reduction’, they did not know what it meant in practice for police. Knowing that IDU is a major driver of the HIV epidemic in Vietnam, some police described their role in HIV prevention as being the prevention of drug use and monitoring of drug users. Although the 2006 HIV/AIDS Law states that infected people have the right to privacy and their sero-status being kept confidential (Article 4.d), one District Police Chief, who claimed to have been trained in harm reduction policies, stated that ward police bear the greatest responsibility for HIV prevention, part of which was “…to review the names of drug users and which ones have HIV”. He added that the focus of the HIV/AIDS Steering Committee of Hanoi was to reduce drug use in order to reduce HIV. One ward police officer  said the role of police in HIV prevention was ‘clear’ but followed that with comments suggesting this meant drug law enforcement. Most police interviewed said that monitoring and conducting surveillance on drug users was a pervasive police activity.The police need to know who is in the [local drug users’ support program directed by the local authorities], their phone number, where they live and so on, so that they know who they need to keep under surveillance. Also, the police help the drug users [after they are released from the 06 centre], give them [encouragement] and consult with their family to help them prevent drug use again and to help them get a job. Police around the world use a variety of methods to gather intelligence about criminal activities. The following quote describes a surveillance technique used by Vietnamese police for drug law enforcement.The [ward] police mostly sit on the coffee corner and pretend they are reading a book or the paper, but they are really listening to people talk and finding out about things. Many criminals hang out on the coffee corner. The police wear plain clothes for this. Although aware of the legality of harm reduction approaches such as needle and syringe programs (NSPs), some police explicitly stated they did not support NSPs, and instead exploited the existence of sites where NS are obtained as opportunities for police to identify IDUs “Conduct frequent surveillance all areas where drugs are used and then locate and seize syringes”; and “Getting all organisations and associations to collect all needles and syringes in the community according to [laws on] drugs and prostitution control”.When asked if police were aware of any policies regarding their role in or near places to procure NS, over half of respondents reported that they were Figure . The surIt is clear from the previous responses and Figure With respect to methadone maintenance therapy (MMT), although most police were aware of the therapy’s benefits in reducing HIV risk through reduced needle sharing among IDUs, almost half (11) of police surveyed saw the primary benefit of MMT as the subsequent reduction in crime, rather than a reduction in HIV risk Pressure on police to identify and arrest drug users in their area was described as a stressor for ward police.Actually, the ward police don’t really like [crack-down] campaigns but we must do it. We are under pressure. It is hard work. Because nowadays the criminals know the campaigns, they know when they happen so they keep a low profile; so do the drug users. They can hide in another ward. In some campaigns, ward police in another ward or district might catch the drug users from your own ward who are hiding there. If they haven’t been profiled [by you] it’s a big problem. It is our biggest fear. Quotas for arresting IDUs and sending them to detention centres are part of the performance measurement system. These apply both to individual police and to the ward as a whole. get no more awards, but the focus will be on the capacity of the Ward Chief… If the [quota] is not met for many years and [the ward police] can’t achieve their action plan the Chief will be rotated to another place and replaced by a new Chief. That’s why every year the Chief decides each person’s action plan. Each person will be allocated three cases. But the more [arrests] you make the more prestige for the officer, so everybody is trying to do their best. Opportunities to be recognised for their performance through receiving certificates of merit for drug arrests may also prompt police to take action against drug use.Happiness at work is when police can feel good because they have [conducted a good investigation]; they can feel good about it for years. Vietnamese police sometimes get a certificate for good work which is a kind of benefit....It is not just performance measurement indicators that may influence police behaviour regarding drugs, users and harm reduction. During key informant interviews, some police reported that discretion was used at times for the following reasons: police were too busy and had to prioritise responding to more serious offences, police regarded the drug user as being from a ‘good’ family or that the drug user was not ‘causing problems’ in the community. As the following quote illustrates, local police do have some discretion, which almost all police interviewed agreed was commonly used. Discretion is particularly relevant for the critical domain of police-community relationships; this emerges in decisions not to enforce the law in particular cases, especially first-time offences considered lesser infractions.One of the important things [to note is], we just use the law and punish people when the issue is serious. We try to help people to understand the law and give them a second chance, and then if they do it again we will use the law. Where minor crimes are committed, we never use the law. In Vietnam we consider the relationship between the police and the community the most important so we only use the law if needed. This is the reality in law enforcement. Sometimes minor infringements are not reported. The question of discretion, its use and purpose, was also put to police in the survey. Responses in Figure It was interesting that the obligation placed on ward police to get to know each individual in the area had an unexpectedly positive impact on police perceptions of drug users; a degree of empathy developed through this familiarity, as is evident from the following quote.As a student I thought all drug users were bad people and we had to stay away [from them]. I was scared of them all. But after I joined the police, I had to talk and deal with the drug users … All the time I have to keep an eye on the drug users, and now I feel normal about them, not scared. I’ve concluded that not all drug users are bad people because there are so many different reasons why they take drugs, like family break ups or peer pressure.Interviews with police from the international co-ordination arm of MoPS indicated that ward police were not considered as important actors in the realm of harm reduction. This perception may be influenced by the Ordinance on Commune Police 2008 which refers to the ward/commune police as a ‘part-time armed force in the organizational system of the People’s Police’ (Article 3)  are not trained. They might find out about harm reduction by reading the law but I don’t know. I don’t know how they would learn about it. So far we have concentrated on the provincial level and maybe some police at the district level. We would like to train ward police but it is very difficult to train so many police. Maybe in the future we will plan to train ward police, but not yet. Interviewees reported that not only was there a lack of police training in harm reduction at the ward level, but also that it is unclear how district and higher level police, while aware of harm reduction, actually disseminate that knowledge to enable harm reduction approaches to be implemented by police in the field. As the following quote demonstrates, it appears that ward police are left to rely only on written guidelines, which may be inadequate for concrete decision-making.The HIV/AIDS Steering Committee of Hanoi…organises training for the district level [police], but just for the leaders and the commanders, and those in key roles … We have a guidance book in every ward police station. They will have this for MMT and they already have it for NSP; these were sent out to every ward police station. (District B Police Chief)The Ordinance on Commune Police 2008 clearly indicates that the specified tasks of the ward police make them appropriate targets for harm reduction information. Perceptions of organisational recruitment and training procedures, however, may impact upon perceptions of the ward level police capability in executing their duties, as the following quote suggests.After I met the ward police they were much smarter than I expected even though they only went to the Police College. We found an inconsistent approach to policy dissemination within the law enforcement sector. Policy directives or official letters are common ways in which senior police communicate policy information to the ward level. According to a Vietnamese UN agency researcher, the provincial level will disseminate a law, policy document or letter but “the documents are normally simplistic, with not much detail,” leaving it up to the subordinate levels to interpret and implement. This respondent went on to say that “a good leader will think of the local context,” and revise the document to include greater detail, but if the leader is lazy or does not support the policy he/she will forward the document down the hierarchy without providing further guidance for localised implementation.Due to a lack of access to technology at ward police stations, dissemination of information often relied upon fax or face-to-face meetings.[District level] Counter-narcotics police are allocated maybe three wards each and they have to keep in touch and share information with their wards. The Counter-narcotics police work at the district level and they go to the wards just for meetings … Every month the Counter-narcotics police have a meeting with the ward police to share information about drugs and to tell them what is going on in the ward. While some district level police had frequent contact with ward police, those interviewed were not aware of any communication about harm reduction programs or approaches. When asked about how harm reduction training or advocacy targeted at police is communicated to the lower levels of the hierarchy, the director of an internationally-funded harm reduction project in Vietnam responded, “We don’t know. This is a problem. Our project only works at the Central and Provincial level.” A former Central level police officer also indicated that there was uneven communication, at best, regarding harm reduction within the policing organisation.When I was training, it would only be one person from the provincial level. I don’t think they would have passed on the information down to the ward level, maybe just among some people in their division. According to a Vietnamese NGO researcher, harm reduction advocacy in Vietnam has typically targeted senior police and authorities, without any mechanisms to reach lower levels. The resulting lack of awareness among lower level police meant a continuation of the traditional drug control approaches.Maybe at best some police at the district level know [about harm reduction] but I don’t see any effort to go down to the lower level. [The senior levels of police] don’t collaborate and so [the ward police] do their things like drug control and arrest drug users and lock them up to keep the streets clean or they put them in detention or prison. (Vietnamese NGO researcher)This study, conducted between 2010 and 2012, reviewed secondary sources and conducted stakeholder interviews and a survey with police to identify the nature and impact of harm reduction advocacy at ward level in urban Vietnam. Given the fact that the survey sample is small and interviewee responses impossible to verify for accuracy, our observations and conclusions are couched in general terms. Despite these limitations, the consistency of responses and the use of multiple methods (including secondary sources) offers some confidence that our findings address gaps in understanding of the critical role played by grassroots police in HIV prevention.Official HIV/AIDS policy in Vietnam, expressed through the National Strategy on HIV/AIDS  and DecrDrug law enforcement and, particularly, crackdowns against drug users, are common practice in Vietnam. These instil fear in drug users about being caught carrying injecting equipment . LegalisOur study found that even though key harm reduction programs have a legal foundation in Vietnam, police openly acknowledged engaging in activities such as monitoring pharmacies to identify IDUs accessing clean NS which has been shown to discourage uptake of these programs. Clearly, public policy alone is insufficient without active mechanisms for its dissemination, acceptance and uptake. In the absence of such mechanisms, particularly at street level, other influences act as counterweights to policing. These include the quota system for compulsory detention, internal police disciplinary action and performance review based on the primacy of drug control.In her study of Australian policing among visible  minorities, Chan argues for the need to “consider our state of knowledge about change” among police , andWard police could be regarded as street-level bureaucrats in the language of Lipsky’s typology of the process of policy implementation . His strAs our research findings have demonstrated, ignoring the role of ward police as important actors in policy implementation could further thwart the implementation of harm reduction policies as envisaged by the National Assembly of Vietnam. Ward police, due to their intimacy with local populations, are ideally placed to negotiate the delicate balance between their obligations to deter criminality, ensure safety, and promote effective HIV prevention strategies. Their potential to exercise discretion in this sphere represents a lost opportunity if ward police are not armed with current knowledge about the efficacy and likely public security advantages of harm reduction measures, as well as about their legitimate role in safeguarding and promoting these measures. It is unfortunate and paradoxical that the relatively lower status of ward police in the law enforcement hierarchy has appeared to result in their tacit exclusion from active advocacy and training.Whilst it is desirable to have harm reduction covered as part of formal police recruit training, it has been argued that ongoing training is more important for the deeper consolidation of particular policing practices . For exaProject managers, researchers and harm reduction staff must better understand internal police organisational structures and cultures to identify the most effective and efficient strategy to inform and engage the law enforcement sector in Vietnam. The results of this study suggest a range of strategies may be relevant, from capacity building for better internal dissemination systems, to advocating with senior levels on behalf of training for street police on the basis of their potential role in facilitating or inhibiting harm reduction programs. However, it is also essential, based on our findings, that the apparent ambiguities and contradictions between laws to control HIV and to control drugs be discussed more openly in order to clarify the primacy of each for street-level police.Written informed consent was obtained from the patient for publication of this report and any accompanying images.The author(s) declare that they have no competing interests.MJ was primary researcher conducting field research, analysis and writing this paper; NC and MM responsible for supervision of research, design and writing; and, GM responsible for liaison, co-ordination and writing. All authors read and approved the final manuscript.


Prolonged immobility associated with gaming may therefore be an important risk factor for venous thromboembolism. We report a case of deep vein thrombosis associated with prolonged playing of PlayStation® games for almost eight hours a day for four consecutive days. Doppler ultrasound of the left leg confirmed extensive left leg deep venous thrombosis requiring thrombolysis and anticoagulation.A 31-year-old Caucasian man, an exterior painter, presented with a three-day history of left leg pain and swelling after playing PlayStationVideo gaming should be considered a risk factor for venous thromboembolism. Further studies are needed to estimate the degree of risk associated with prolonged periods of playing video games, and education for preventing venous thrombosis should be provided to gamers. Long-distance air travel and prolonged sitting in relation to work or recreation have been shown to increase the risk of venous thrombosis ,2. A rec® games. He would play for seven to eight hours continuously without getting off the bed. On the second day, he developed left leg pain with associated calf swelling and erythema, but, despite increasing discomfort, continued to play video games until presenting two days later. There was no history of trauma to his left leg, recent surgery, or previous venous thrombosis. There was no family history of venous thrombosis. On examination there was marked swelling of the leg with dilated superficial veins. Doppler ultrasound of his left leg confirmed extensive deep venous thrombosis involving the origin of the left common iliac vein down to level of the distal left femoral vein and proximal long saphenous vein, with features indicating complete occlusion. He was commenced on anticoagulation with subcutaneous enoxaparin, and subsequently underwent thrombolysis with heparin and urokinase. A thrombophilia screen was negative.A 31-year-old Caucasian man, an exterior painter, presented with left leg pain and swelling. He was on holiday and spent each day sitting on his bed with his legs outstretched playing PlayStationet al. used the term ‘eThrombosis’ to describe the 21st century variant of venous thrombosis and reported a case of life-threatening VTE in association with prolonged immobility sitting at a computer [The pathophysiology of venous thrombosis involves venous stasis, hypercoagulability, and endothelial dysfunction, which was termed Virchow’s triad, described initially in 1856 by the German pathologist Ruldoph Virchow . The asscomputer .There has been a growing popularity of video games over the last 30 years, with annual sales in the United States of more than $11 billion. The age of gamers has increased and in 2012, 37 percent of American video game players were older than 36 years of age . The timWhile prolonged seated immobility is a risk factor for the development of venous thrombosis, there could be other factors related to prolonged gaming that are involved in the pathogenesis of VTE. Previous research has shown an increase in blood pressure and heart rate with exposure to violent video games as part of the physiological stress response , suggestWith the growing popularity of video games, the burden of this presentation of venous thrombosis is likely to increase. Further studies are needed to estimate the degree of risk associated with prolonged periods of playing video games, and education for preventing venous thrombosis should be provided to gamers.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.LC participated in writing and editing the report. CW and HB participated in editing the report. All authors read and approved the final manuscript.