Stories play a fundamental role in human culture. They provide a mechanism for sharing cultural identity, imparting knowledge, revealing beliefs, reinforcing social bonds and providing entertainment that is central to all human societies. Here we investigated the extent to which the delivery medium of a story  affected self-reported and physiologically measured engagement with the narrative. Although participants self-reported greater involvement for watching video relative to listening to auditory scenes, stronger physiological responses were recorded for auditory stories. Sensors placed at their wrists showed higher and more variable heart rates, greater electrodermal activity, and even higher body temperatures. We interpret these findings as evidence that the stories were more cognitively and emotionally engaging at a physiological level when presented in an auditory format. This may be because listening to a story, rather than watching a video, is a more active process of co-creation, and that this imaginative process in the listener’s mind is detectable on the skin at their wrist. Stories help us make sense of the world. Narratives provide links to traditions, legends, archetypes, myths, and symbols and help connect us to others by forming and stabilizing social bonds, by reinforcing and enhancing the group’s memory, and by providing shared entertainment. Our oldest narratives date back many thousands of years and pre-date the advent of writing. For the majority of human history, stories were synonymous with the oral tradition; audiences listened to a story teller imparting a tale. In modern cultures, stories are just as important but now are delivered in a variety of mediums including written books , videos (TV and films), and as auditory narratives. Here we investigated the extent to which the medium of a story  affected one’s engagement with the narrative.4. In some cases, it refers to cognitive operations such as attention, effort or agency when performing a task2 while in others it refers more generally to participation in activities4. In this paper, we operationalize engagement in two ways: self-reported engagement of a narrative experience and physiological engagement as an indirect measure of the mental processing that generated that experience.“Engagement” is construed very differently across the literature7. Indeed, there is evidence that narratives recreate a similar pattern of brain activity in the listener that was produced by the storyteller. Silbert et al.8 used functional magnetic resonance imaging (fMRI) to scan the brain of a volunteer speaking a 15-min personal story. Another set of volunteers then listened to this story while having their brains scanned. The authors identified the set of brain regions engaged by these tasks and found widespread coupling between activity in the speaker’s brain and that in the listeners’ brains. In other words, the act of listening to the narrative recreated the same basic pattern of brain activity as telling the story. This could mean that listeners share the same mental representations as the speaker10, but at a minimum it demonstrates that listening to the story produces similar neural processing, which may suggest it is similar to experiencing the speaker’s memory of the events. Moreover, activation was not limited to regions of the brain classically related to language, but also involved emotional, sensory and motor systems consistent with the notion that at some level, the listener actually experiences the story.A good story takes the listener on a journey, evoking cognitive and emotional responses such that the listener experiences the story through a process of mental simulation of the people, events, actions, places and emotions from the narrative, as if these were being experienced directly11 recently reviewed a wide field of evidence investigating the differences between narrative processing of spoken or written stories, and moving images. They concluded that, ‘verbal narrative generates more diverse responses than moving image narrative,’ and recommend that future research focuses on differences in neural mechanism between the two. In this paper, we rise to that challenge, and predict that different levels of mental processing of auditory and video narratives will be reflected in different levels of physiological activity, specifically in heart rate, electrodermal activity and body temperature.Historically, story-telling relied primarily on spoken language, and then more recently on written language, but in the modern era video has emerged as a major narrative tool as well. The main difference between these channels is the information they provide. Spoken words come in a single modality, namely audition, and have a very abstract relation to the content of the narrative. Consider a story that contains the sentence: “The was house ablaze.” A listener will correctly interpret this to mean that the house was on fire and possibly imagine what it might be like but the actual physical stimulus—in this case, changes in acoustic energy over time—is unrelated to the content being conveyed except through the interpretation of language. Video, on the other hand, is more closely related to the content. Seeing a video of a burning house, hearing the sounds of the fire—these are physical stimuli that directly convey the information without interpretation and without language. In other words, because of their different information content, these two channels require very different processing despite the fact that they can convey identical narrative content. Oral and written stories require a more active processing in the sense that the listener/reader reconstructs a personalized interpretation of the narrative. In contrast, watching video is a more passive process due to the fact that there is less scope for personal interpretation. Indeed, Jajdelska et al.14. Linking heart rate to specific cognitive states, however, is not straightforward. Andreassi12 claimed that heart rates increase when people focus more on internal information and less on the external environment while Papillo and Shapiro15 argue that increased heart rate demonstrates cognitive elaboration, that is, the amplification of basic information processing activities such as encoding, attention, and emotional processing through discussion, meta-cognition or imagination17. If narratives delivered in audiobook form require greater active mental simulation than watching videos, then we would expect to see increased heart rate for audio relative to video stories.In its simplest form, increased heart rate is an indicator of increased effort and serves as an indirect measure of cognitive and emotional engagement. Changes in heart rate have been linked to increased information processing demands and/or greater mental effort19. One of the key emotional centres in the brain, the amygdala, stimulates the adrenal medulla, releasing the hormone adrenaline and enhancing autonomic nervous system activity. One consequence is the constriction of sweat glands in the dermis which increase skin conductance. EDA, therefore, provides an indirect method for measuring emotional arousal18 that can be used to evaluate whether stories presented in either the auditory or visual modality differentially engage emotional responses.Electrodermal activity (EDA) is another physiological measure of engagement that is typically understood as an index of emotional arousal20. Since thermoregulation is biologically costly, IJzerman et al.21 argue that many social animals have evolved to share body warmth between themselves by directing blood towards the skin, and then huddling or engaging in skin-to-skin contact. Indeed, skin temperature on the hands increased by a fraction of a degree when participants watched film clips that produced positive, happy affect22 or engaged in positive social interactions23 and Kistler et al.24 found decreases in finger temperature in response to fear-inducing stimuli. By measuring body temperature at the wrist, we gain an independent physiological measure of potential differences between audiobook and video stories.Changes in body surface temperature have recently been suggested to correlate with mood and social contextGame of Thrones book25 we chose the passage in which Arya witnesses her father’s beheading, and the same scene in the HBO adaptation26.The question we asked here is whether a difference in the delivery channel would influence self report and physiological engagement with the narrative. Participants experienced the same set of eight scenes from fictional stories. For each story, participants either heard a passage from an audiobook, or saw a TV or movie adaptation of the same scene. For example, from the 28. Our stimuli are not equivalent in either of these senses. If a crowd scene is paused in the Game of Thrones scene, for example, a viewer could read off the colour of the clothing for every member in the shot. These are details that are not mentioned at all in the spoken narrative. But listeners to the audiobook are told, for example that Arya wondered why her sister looked happy. That information is either not present in the video at all, or has to be inferred from the actor’s emotions. Our claim therefore is not that the stimuli and informationally or computational equivalent, but that they are narratively equivalent, in the sense that the same story elements are present in each. The ways that stories are realised in video versus spoken word—the different information in each format and the different demands that they place upon the reader or viewer engaged in the narrative—are precisely what that we want to contrast experimentally.Stimuli can be informationally equivalent if the same information can be extracted from each and computationally equivalent if it can be extracted with the same effort29 that quantified their immersion in the narrative, their attention to the story, their closeness to the characters and their sense of presence in the narrative world.While watching and listening to the stories, biometric sensors were used to measure physiological engagement via heart rate, electrodermal activity and body temperature. All of these physiological signals are also affected by physical activity, and so we used accelerometers on the sensors to track and account for body motion. After each story, participants answered twelve questions of a narrative engagement scale109 participants were recruited from UCL’s subject pool and paid £10 for participation. Seven participants were excluded due to equipment failure or participant drop out. Of the 102  who completed the experiment, their ages ranged from 18 to 55 with an average age of 29 years old (SD = 10.5). The sensors we used sometimes failed to record complete data, due to problems with the sensor, incorrect placement, the participant adjusting the wristband, and so on. The failure rate differed for different sensors as they were more or less susceptible to interruption and artifacts. After identifying and cleaning problematic recordings, we were left with 95 participants with complete heart rate and acceleration data, 76 with temperature data, and 62 with complete electrodermal activity data. This research was approved by the UCL Research Ethics Panel [#3828/003] in accordance with the Declaration of Helsinki. Participants provided written/electronic informed consent.Pride and Prejudice30 and Great Expectations31; from action novels we chose The Girl on the Train32 and The DaVinci Code33; from crime fiction we chose Hound of the Baskervilles34 and The Silence of the Lambs35 and from Science Fiction/Fantasy we chose Alien: River of Pain36 and A Song of Ice and Fire (Game of Thrones)25. Audiobooks were readings from the original texts, rather than acted out adapted audio plays, with sound effects and different actors. Videos were extracted from film or TV adaptations of the books. Each story was selected because they were well-known examples of their genres and because audio and video adaptations of the novel were available. For each, we selected an emotionally charged scene where the audio and video versions were as similar as possible. Though they covered the same events, due to their nature, the audiobooks tended to be slightly longer  than the video versions . A description of the eight scenes is included in the Supplemental Information.We chose eight works of fiction spanning four different genres. From classic literature we selected 37. For our purposes, we operationalised participants’ self-reported engagement in the stories by adapted the narrative engagement scale developed by Busselle and Bilandzic29, which is based on a mental models approach. This measure has the advantage of being validated across four dimensions of experiential engagement, which have been shown to be related to physiological measures14. The original scale referred to watching a program or film, and so we modified the language slightly to refer to stories that could be seen or heard. The scale is divided into four subscales with three questions relating to each: character engagement (e.g. “I understand why the main character thought and behaved as they did in the story”), narrative understanding (e.g. “I had hard time recognizing the thread of the story”), attentional focus (e.g. “I had a hard time keeping my mind on the story”), and narrative presence .The nature of narrative ‘engagement’ is notoriously difficult to define across contexts and disciplines38 and participants wore headphones throughout. They first completed a short demographic questionnaire and a survey asking about their consumption of movies, books and audiobooks.Participants were informed about the experiment and gave their consent to take part. They were fitted with an Empatica E4 wrist sensor, which captured their heart rate (HR), electrodermal activity (EDA), wrist temperature and acceleration in 3 dimensions. They were led into a sound attenuated cubicle. The experiment was run on a PC, using the Gorilla online testing platformParticipants were presented with eight stories, in a block of four audio books and four videos. Across participants we counterbalanced the order of these blocks, and which stories were presented as a video or audio book. In each trial, the participant first read a short synopsis of the plot and characters in the story so far, to give a context for the excerpt. They then watched the video onscreen or listened to the story while looking at a black screen. After presentation, participants reported whether or not they had experienced that excerpt before or not, and dragged a slider to indicate how familiar the characters were, and how familiar the scene was. Then they rated the 12 statements of the narrative engagement questionnaire, using a 7-point Likert scale that ranged from “strongly disagree” to “strongly agree.” The experiment took approximately an hour to administer. On completion the participants were debriefed, thanked and paid for their time.39 to clean the EDA data using the acceleration data. The 3-dimensional acceleration vectors were then simplified into a single acceleration value that expressed movement magnitude in any direction.Physiological data were aligned to stimulus and condition information and trimmed to trial durations using the Universal Time Coordinates that were recorded by the Empatica sensors and the Gorilla system. EDA measurements are typically susceptible to movement artifacts, and so we used the EDA Explorer algorithmhttps://osf.io/u452g/.All physiological measures were normalised for each participant. That is, the data were converted to a normal distribution by mean centring to zero and dividing by the standard deviation. This removed any baseline differences between individuals (e.g. their resting heart rates) and allowed us to focus on differences between story modalities within each participants’ data. Across the duration of the experiment, participants heart rates and body temperatures decreased overall, and their skin conductance changed  was higher by 0.02 micro Siemens and they were roughly a third of a degree warmer in their body temperature (0.34 °C).Game of Thrones story in two modalities. Since the audiobook and video had different durations, we have plotted our measures as a function of the proportion of the story time. The differences shown for this item were echoed across all stories .Figure 40.Figure 42. In the Supplementary Information, we also report more traditional ANOVAs analyses, which produced the same pattern of conclusions.The Bayesian approach allowed us to directly quantify the effects of modality on behavioural and physiological measures and the strength of evidence in support of any differences, avoiding some of the problems associated with null hypothesis testingrstanarm package43 to model the data, and the psycho package44 to interpret it. In our models, we employed weakly informative priors that were scaled following the standard rstanarm procedure.For each of the dependent variables reported below, we used mixed models with fixed effects for story modality, which was varied within participants, and block order and stimuli order, which were varied between participants as counterbalancing measures. We used random effects for participants, story, and trial number, to model changes in measures during the course of the experimental hour. We used R (version 3.4.3) the From 4,000 simulations, we generated estimates of the posterior distributions of the model parameter coefficients, which quantify the strength of the evidence that each experimental condition influenced behaviour. Full details of our models, priors, and all parameter estimates are given in the SI.Here we report estimates of the differences between audio and video modalities. The full probability distributions of these difference estimates are shown in the bottom row of Fig. There was strong evidence that participants rated their engagement higher for videos rather than audiobooks. Summing the 3 questions for each subscale gave a value between 3 and 21. For their attention to the story, the median of the posterior distribution for the effect of the video condition was 3.62 points higher (MPE > 99.99%). For their engagement with the narrative, the median was 1.75 points higher (MPE > 99.99%). For their ratings of presence, the median was 1.95 points higher (MPE > 99.99%). For rated engagement with characters, there was a smaller but reliable difference of 0.35 points in favour of the videos (MPE = 98.23%). In other words, there was strong evidence that participants self-reported greater engagement for videos relative to audio stories for all measures of engagement.The physiological evidence consistently demonstrated stronger responses for the audio relative to the video condition. The median estimate of normalized mean heart rates was 0.20 higher for audiobooks (MPE > 99.99%). The median standard deviation of heart rates was also greater by 0.08 (MPE = 99.75%). The median of the estimated EDA readings was 0.28 higher for audio books (MPE > 99.99%), and participants had a median estimate of normalised wrist temperature that was 0.19 higher for audiobooks (MPE = 99.35%).One possible explanation for the higher physiological responses may be that participants were more physically active when listening to audiobooks—that is, they could have been fidgeting more, consistent with their self-reported lower engagement. To assess this, we examined the acceleration data from the Empatica sensors. There was no strong evidence that participants moved more during audiobooks, with the median estimated difference at 0.019 (MPE = 79.32%). The lack of an effect suggests that the differences in heart rate, EDA and temperature were not due to physical movement, but instead due to the emotional and cognitive differences in listening to audiobooks.A second potential confound between the modalities was the fact that on average, audio scenes were longer than the equivalent video clips by approximately 100 s. To avoid cumulative differences in effort over time, we compare mean scores. Even so, if there were an upward linear trend with time, this could potentially inflate the difference with the longer clips showing larger effects. The data from all eight stories are shown in Supplemental Fig. On a trial by trial basis, we computed how familiar the story and characters were to participants. Reported familiarity correlated positively and significantly with each of the four dimensions of reported engagement, but crucially, these correlations held equally for both audio and visual modalities . Reported familiarity did not correlate with any physiological responses, either for all items together, or for audio and video items separately. We concluded that while participants found familiar stories more engaging overall, this does not reveal anything about differences between audio and video narratives.The term ‘engagement’ has different levels of meaning. In one sense, engagement relates to the richness of the experience while in another, is related to the degree of mental processing that generates that experience. In the case of audio versus video narratives, we have found a case where those two senses diverge.Participants reported higher levels of engagement while watching video scenes compared to listening to audio scenes. They attended more, showed greater narrative understanding and reported greater narrative presence when watching video clips, suggesting that they not only found video narratives easier to comprehend, but also immersed themselves more fully in the world created by the video narratives. In other words, people found the videos more engaging according to their self-report. Interestingly, their implicit physiological measures told a different story. On average, heart rates were higher and more variable, ectodermal activity was greater and temperatures were raised when listening to audio narratives than when watching video narratives. These findings suggest that listening to audio stories engaged greater cognitive and emotional processing than watching videos.If increased heart rate is truly an indicator of increased effort, these results are consistent with the hypothesis that listening to a story is a more active process, and therefore more cognitively and emotionally engaging than viewing the same story. In essence, the listener mentally simulates the narrative more so than viewers of the narrative, who more passively process the visualization provided by the video’s director.45. All three story-types activated the temporal lobes and Broca’s area, as expected, but the interesting findings pertained to the differences between the stories. Specifically, visually vivid stories activated the occipito-parietal junction and the pre-cuneus, two regions associated with visuo-spatial processing. Action-based stories, in contrast, activated regions of premotor cortex while emotionally laden stories activated parts of the limbic system typically linked to affective responses, demonstrating that listening to stories engaged not only core “language regions” of the brain such as Broca’s area, but also recruited additional brain systems depending on the context. This is consistent with the notion that understanding a narrative involves mental simulation that retrieve the listener’s perceptual, motor, and affective knowledge through reactivation of the neural systems responsible for perception, action, and emotion.Of course, this is a relative difference: understanding the narrative of a film certainly engages a range of cognitive and emotional processes. A recent study illustrated this by measuring brain activity while volunteers listened to stories that were either visually vivid, action-based, or emotionally charged46 which means that listeners/readers are frequently resolving ambiguities, often without even noticing them. For example, in a sentence like “The woman made the toast with a new microphone,” the word “toast” is ambiguous—it could refer to cooked bread or a call to drink together. It is not until the word “microphone” is encountered that the meaning becomes clear. Although this appears to occur effortlessly, resolving ambiguity is a complex process involving multiple cognitive operations, supported by a set of brain regions including Broca’s area and posterior parts of the temporal lobe48. There is, however, less ambiguity in the video equivalent, where the image of a woman speaking into a microphone is clear from the outset. Even if they are unaware of it, the listener is working harder to understand the story than a person viewing a video would. As a result, listening to a story will be a more active and therefore more demanding process than watching the video.Another fundamental difference between purely language-based stories and video is the presence of semantic ambiguity. Semantic ambiguity refers to the fact that most words in English have more than one meaningThere was also strong evidence from the physiological data for greater emotional engagement with the audio relative to the video versions of the stories. We observed significantly higher electrodermal activity (EDA) and skin temperatures when participants listened to audio narratives compared to when they watched the same narratives as video. These results demonstrate that when listening to audio stories, participants experienced greater arousal than when watching video stories.19. As a result, there is no way to disentangle the two based solely on heart rate or EDA measures. A more fundamental reason, however, is that emotions are simply not distinct from other forms of cognition—despite a widespread assumption to the contrary50, which is why we choose to interpret the current findings as evidence of “cognitive and emotional engagement.”Physiological measures such as heart rate, EDA and skin temperature are indirect indices of engagement. In each case the measure is a summary of autonomic nervous system activity which include additional factors beyond cognitive and emotional engagement . Moreover, it is difficult to convincingly disentangle cognition from emotion for both practical and theoretical reasons. In practice, cognitive effort and emotional arousal have common effects on the autonomous nervous system that drive the physiological responses being measured hereOf course, it is possible that these conclusions are specific to the particular narratives that we selected. Though they span genres, they are all cases of successful narratives, in the sense that people chose to record audio books and make film adaptions of them. What is remarkable, however, is that despite their differences in tone and content, the pattern of differences we found between conditions are replicated very consistently across items, and across the time course of items (see SI Fig. We found that participants perceived themselves to be more concentrated and engaged while watching video narratives, but their physiological responses revealed more cognitive and emotional engagement while listening to audio narratives. Why do they feel more engaged if their bodies say otherwise? We suggest that spoken narratives require the participant to be an actively engaged listener, whereas videos deliver rich stimulation to a more passive viewer. The pictures in the listener’s mind may not be as vivid and as detailed as those onscreen, and so auditory narratives are rated explicitly as less engaging; yet the imaginative generation of those images requires greater cognitive and emotional processing, and so they are physiologically more engaging.Supplementary information


Our video-based system showed a bias of negative 1.3 breaths and root mean square error of 6.36 breaths per minute compared to standard continuous monitoring. Further work is needed to evaluate the ability of video-based monitors to observe clinical changes in a larger population of patients over extended periods of time.Respiratory rate (RR) has been shown to be a reliable predictor of cardio-pulmonary deterioration, but standard RR monitoring methods in the neonatal intensive care units (NICU) with contact leads have been related to iatrogenic complications. Video-based monitoring is a potential non-contact system that could improve patient care. This iterative design study developed a novel algorithm that produced RR from footage analyzed from stable NICU patients in open cribs with corrected gestational ages ranging from 33 to 40 weeks. The final algorithm used a proprietary technique of micromotion and stationarity detection (MSD) to model background noise to be able to amplify and record respiratory motions. We found significant correlation— The drive and control of breaths is an intricate system involving the circulatory, pulmonary, and central nervous systems. Chemoreceptors throughout the body monitor for hypoxia and hypercarbia, altering respiratory rate (RR) to maintain organ perfusion and optimal pH. Evidence has shown RR to be a better predictor of cardio-pulmonary deterioration than blood pressure and pulse rate . In the Traditionally, the gold standard for measuring RR is counting breaths for a minute while auscultating the patient or palpating for chest rise. While this is the most accurate, it is time consuming and not practical for an intensive care unit where continuous vital signs monitoring is required. Since the late 1800s, multiple innovations have been developed to automate measurements of respiration . Early iSimilar to RIP, impedance pneumography (IMP) measures changes in electrical signal secondary to the movements of the chest and diaphragm and has been widely adapted to multiple clinical settings. IMP uses mathematical algorithms to convert other electronic signals such as pulse oximeters and electrocardiograms (ECGs) to a respiratory wave form and RR, while RIP is derived directly from the attached straps. IMP can be integrated into standard continuous monitoring systems used by most hospitals . While aNevertheless, there are several limitations of IMP. Information has to be gathered from electronic leads attached directly to the skin, and the signal needs to be amplified to be measured, making it susceptible to artifacts or noise. Artifacts and signal noise can originate from inadequate attachment of the electronic leads as well as any movement of the patient not related to breathing. In the neonatal population, these limitations are particularly apparent and produce several unique adverse outcomes. The frequency of false alarms secondary to the frequent movement of newborns is associated with provider alarm fatigue, infant hearing loss, and a disruptive environment for development ,10,11,12Several innovations have been developed for non-contact monitoring in neonatology to minimize risk of dermal injury and alarm fatigue in infants. A variety of techniques have been studied from radio wave signaling, ultrasound, imaging photoplethysmography (PPG), and video-based respiratory monitors. In controlled environments, they have been shown to correlate with ECG monitoring with correlation coefficients from 0.79 to 0.92 ,14,15,16We conducted a course of study focused on a video-based respiratory monitoring system that extracts a respiratory waveform and rate without augmenting the infant’s surrounding or attire. Unlike past studies, this system extracts data on fully clothed or swaddled infants in a neonatal intensive care unit (NICU) with a variety of lighting and camera orientations. Through an iterative approach, we demonstrate a proprietary technique that is able to compensate for background signal noise while amplifying and measuring RR.This study was performed at a single center, Lucile Packard Children’s Hospital at Stanford University. Patients in the neonatal intensive care unit (NICU) and step-down intermediate care nursery were enrolled in this study. Institutional Review Board (IRB) approval was obtained through the Stanford University Institutional Review Board. All monitoring was performed with written informed consent from parents and guardians in the NICU. Patients who were in an open crib, without significant complications, and not already enrolled in another study were eligible to enroll. Convenience sampling was used, with subjects recruited based on attending physician referral of eligible patients. Infants with concern for active infection, need for supplemental oxygen therapy, or vasopressors were excluded. To ensure patient safety, routine medical care and protective measures were not altered during monitoring sessions. Data being obtained from the study were not made available to clinicians during the course of their care for patients.This manuscript describes an iterative design process. The objectives of the design were to identify and measure the respiratory rate of a preterm infant within an open crib through the analysis of camera footage and comparison to current hospital monitoring standards. The iterative process involved sequential algorithm design and application on recorded data. The principle analysis of the study investigated the consistent ability to identify patients within the frame and ability to extract the subjects’ respiratory rate. The secondary analysis compares respiratory rate from our non-contact monitoring to that recorded into the electronic medical record (EMR) by the current hospital standard of respiratory monitoring by ECG impedance pneumography. Any design that could not identify the patient, extract an RR for a majority of subjects, or did not correlate with the current standard was determined to be unsatisfactory, and the study would return to the previous design phase.Data were collected at the bedside as continuous 48-h video recordings from each infant. Footage was recorded on off-the-shelf IP cameras from Wansview with 320X180 resolution at ten frames per second and provided raw frames in YUV format. Cameras were placed approximately 4–6 feet from the bassinet . SimultaIn the initial analysis, algorithms were assessed for consistent ability to identify the location of the patient in the crib, whether the patient was breathing, and finally if the monitoring could track respiration long enough to generate a respiratory rate. Analysis was based on the assumptions that the camera or crib did not move or sway and that the only moving element in the frame was the patient .In the secondary analysis, RR measured by the algorithm was compared to that extracted from standard monitoring data at the same moment in time. Agreement between the two modes of measurements was analyzed using a Bland–Altman plot. The extent and significance of correlation between the algorithm and standard monitoring were performed via linear regression. Finally, assuming complete accuracy of the ECG impedance pneumography measurement of respiratory rate, errors of algorithm measurements were determined by calculating the root mean square error.Eighteen subjects were enrolled and recorded in the study for the period of 2016–2017; one was excluded from final analysis due to conflicting documentation. At the time of recording, all infants were under the chronologic age of 10 weeks and had corrected gestational ages of 33–40 weeks. The mean age of patients at time of recording was 5 weeks and 35.5 weeks adjusted. The mean gestational age at birth was 30 weeks and 3 days. The population was 65% male and included a variety of racial backgrounds, with the largest group being White at 35%. Race was defined per electronic medical record with Asian including individuals of Indian and Southeast Asian descent. All subjects had various comorbidities of prematurity, with the prevalence of the most pertinent—apnea of prematurity, history of respiratory distress syndrome, chronic lung disease, and anemia of prematurity—demonstrated in The design process went through three cycles creating and testing three different algorithms: Eulerian video magnification followed by motion extraction, principal flow field, micromotion and stationarity detection. The final algorithm, micromotion and stationarity detection, achieved the design goals of consistently providing an RR for the subject and went on to the secondary analysis, comparing it to the continuous vital signs recorded into the subject’s EMR. The initial technique for extracting RR from footage was an Eulerian video magnification (EVM) algorithm to amplify movement, followed by a motion history image (MHI) algorithm to extract the motion.EVM amplification has been described in other fields . Our algThe MHI algorithm then generated the motion between frames by referencing successive binary silhouette images of the baby. The motion gradient between frames was used to calculate the amplitude for the inspiration/expiration signal of the baby’s breath and generate a continuous respiratory waveform. The respiratory rate could then be calculated from the waveform. The process of quantifying motion in a MHI is a unique process and has not been studied to our knowledge.The benefits of the EVM and MHI approach was its ability to magnify small motions, with minimal processing and few artifacts. The critical deficits were the high rates of false positive signals. This was primarily from amplification of noise generated by changes in lighting and infant movement. Principal flow field (PFF) methodology was used in hopes of decreasing the impact of noise and increasing processing speed. Flow fields are a common way to evaluate movement in engineering. To optimize processing speed, our PFFs were performed on segments instead of full frames. This was accomplished by calculating optical flow fields by generating pixel movement gradients between frames. Knowing that inhalation and exhalation would be in the opposite direction allowed us to form flow field matrices localized to pixels representing respiration rather than noise.PFFs were computed using the flow field matrices on the initial frame and adapted for each sequential frame. The PFF was used to generate a continuous respiration signal, which again was used to generate RR.The benefit of PFF was its localized respiratory movements which decreased processing times while picking up similarly minute movements as the EVM algorithm. However, this algorithm was limited due to recurrent false positive readings with no infant present in the crib. This was due to the optical flow fields picking up the best plausible signal that represented respiratory movement even if this motion was actually noise from video capture, video compression, movement artifacts, or lighting changing. As there is always some level of noise, this algorithm would generate respiratory signals and rates even if a baby was not breathing or even if not present in the frame. The final algorithm utilized micromotion and stationarity detection (MSD) and has not previously been studied for this application. To overcome the challenge of finding respiratory motion at a frame-to-frame level without incidentally measuring noise, the MSD analyzed and modeled the noise instead of trying to eliminate it.In order to model noise characteristics, the image was divided into small sub-regions where changes in pixel intensity were measured over time. The model of the noise consisted of standard deviation (SD) measures of the changes in pixel intensity.Assuming that the SD of the change in pixel intensity over a series of frames, with no motion and only noise, would remain relatively small and equal from frame to frame, then a large change in the SD of pixel intensity would indicate a micro movement. This is how imperceptible movements of chest rise and fall could be located and measured.Pixel intensities, or breathing motions, were calculated by taking SD measures of the SD measures. This generated heat maps that represented motion . To deteA significant benefit of the MSD is its insusceptibility to noise and capability to detect whether or not an infant is in the frame and if that infant has had an apneic event, defined as a pause in breathing for greater than 20 s. The MSD algorithm had difficulty with measuring RR while the patient had gross or macro movements, such as movement of arms, leg, or torso with crying or shifting while sleeping. After such movements, the algorithm needs to recalibrate over 100 frames, or 10 s at 10 frames per second, to ensure it has located the subject and is measuring the correct signal. ECG impedance pneumography also cannot extract RR with large patient movements, but recovers more quickly after only a couple of seconds.The secondary analysis was completed by running the MSD analysis on two patients. Their 48 h of video recording was scanned for continuous time frames where the patient remained asleep, relatively still, and unobstructed by staff or parents providing care. The combined continuous uninterrupted video consisted of 21 min and 50 s and contained 246 time points.The MSD algorithm takes 10 s to calibrate, as described above, and then populates an RR every 5 s. The EMR produced a time point every 1 s as long as there was no interruption in the signal. To assure the two data sets represented the same points in time, the RR of 10 sequential timestamps from the video algorithm were assessed against the same time stamp from the EMR, and if there was a large discrepancy, then that series would be considered inaccurate and would not be included in the final data set. After confirmation that the time stamps matched up, respiratory rates from the MSD algorithm were compared to the RR from the EMR at the same corresponding time stamp until there was another interruption in either signal that prevented the two RRs from being generated at the same time. This assessment would then repeat to find the next usable segment of data.The average RR over the approximately 22 min was 65 breaths per minute (BPM) in the EMR data and 67 in the video monitor group. The standard deviations were 18.4 and 19.7, respectively. Both patients recorded were male and Caucasian. Their mean gestation age at birth was 29 weeks and 5 days. Their mean adjusted age at recording was 36 weeks and 2 days. Overlying tracings between the EMR and video monitor over the recording time (in seconds) for both subjects are shown in Comparison between the EMR and MSD respiratory rate via the Bland–Alterman method showed that the video monitoring system had a bias of 1.3 less breaths per minute, and 94.3% of all time point comparisons were between the upper and lower limits of agreement .p value of 0.001. The regression showed an R squared of 90%. Assuming that the EMR data were representative of the true respiration rate, the error of the video-based monitoring system was calculated as 6.36 breaths per minute via a root mean square analysis (A linear regression between the EMR data and those of the camera-based non-contact monitor showed a correlation coefficient or multiple R of 0.948, with a analysis .The main limitation of this study is the relatively small sample size, short recording time, and lack of gold-standard comparison. While correlations are encouraging for the 246 time points recorded, the data were limited to a small population and short time period. As the patients in the secondary analysis were both Caucasian, the lack of diversity potentially limits the generalizability of the technology on a broader population level. This limitation may be mitigated by the technology’s capacity to detect RR through varied infant attire and different color swaddles. Lastly, by selecting relatively stable infants for 48 h of monitoring, our study was not designed to assess whether video monitoring systems can track clinically significant trends in respiratory rate. As this monitor was not available for the clinical team, it could not be assessed whether it had more or less false alarms or missed apneic or tachypnea events. Video-based respiratory monitoring is at the earliest stages of development. However, our study shows the potential for MSD, making this technology equivalent to induction pneumography for at least a stable neonate in an open crib. While there are still a lot of qualifiers to its comparison, it is a major step toward a future without contact respiratory monitoring. Video-based monitoring could be integrated into incubator designs and attached to preexisting hospital cribs. With further validation, this technology could decrease the need for cardiac leads in more stable infants and be an adjunct monitoring tool for critically ill patients as a means to possibly decrease false alarms from patient movement.A next major step for video-based respiratory monitoring systems is to validate the technology in a large cohort study inclusive of a diverse population with varying skin tone, race, sex, age, and clinical stability. Once validated, conducting studies that allow providers to view RR in real time would demonstrate the ability of video-monitoring to screen for apneas and tachypnea in infants. To be trusted in clinical settings, this technology must be shown to be as sensitive as induction pneumography. While preliminary data from this study suggest that it is as sensitive and specific as ECG-based systems, a longer and larger study focused on comparing significant events between the two systems is needed. There may also be opportunities for this technology to reduce false positive alarms, a known issue for hospitalized patients, either by being a more accurate monitor or by providing negative feedback to current monitors.As MSD amplifies and tracks movement by averaging background noise, it has an advantage over induction pneumography which often falls short because of increased noise with faster respiratory rates. A future study comparing video-based respiratory monitoring and ECG induction pneumography to the gold standard of counting breaths for a minute in clinically ill and tachypneic patients could potentially show superiority of video-based systems in monitoring RR.With the majority of pediatric illnesses being respiratory-related and the accessibility of high-quality cameras, such as those present in most personal cell phones, a video-based monitoring system could also have a large impact on outpatient medicine. It is conceivable that this technology could allow healthcare providers to measure RR throughout a telehealth video visit. This would provide valuable information that would aid in the decision-making process of whether or not a patient needs to go to an emergency room or would be safe to be cared for at home. With the SARS-CoV-2 pandemic increasing demand and showing the value of telemedicine visits, this technology could be invaluable.Video-based monitoring using an MSD algorithm is a promising method to measure RR in the neonatal population. This preliminary study shows the arc of development and potential equivalency to the current industry standard of ECG induction pneumography. Further work is needed to continue to evaluate the ability of video-based monitors to record clinically relevant apneic events and other sudden physiological changes in comparison with current monitoring standards.


It was found that the molar mass of JPUA-TDI was doubled compared to JPUA-IPDI. Each resin showed a similar degradation pattern analysed by thermal gravimetric analysis (TGA). For the mechanical properties, the JPUA-IPDI-based coating formulation exhibited a higher hardness value but poor adhesion compared to the JPUA-TDI-based coating formulation. Both types of jatropha-based polyurethane acrylate may potentially be used in an ultraviolet (UV) curing system specifically for clear coat surface applications to replace dependency on petroleum-based chemicals.Crude jatropha oil (JO) was modified to form jatropha oil-based polyol (JOL) via two steps in a chemical reaction known as epoxidation and hydroxylation. JOL was then reacted with isocyanates to produce JO-based polyurethane resin. In this study, two types of isocyanates, 2,4-toluene diisocyanate  and isophorone diisocyanate (IPDI) were introduced to produce JPUA-TDI and JPUA-IPDI respectively. 2,4-TDI is categorised as an aromatic isocyanate whilst IPDI is known as a cycloaliphatic isocyanate. Both JPUA-TDI and JPUA-IPDI were then end-capped by the acrylate functional group of 2-hydroxyethyl methacrylate (HEMA). The effects of that isocyanate structure were investigated for their physico, chemical and thermal properties. The changes of the functional groups during each synthesis step were monitored by FTIR analysis. The appearance of urethane peaks was observed at 1532 cm Polyurethane (PUR) is a versatile resin that can be used for various applications such as coatings, adhesives, sealants and elastomers. Basically, PUR is synthesised by reaction of polyols with isocyanates at a specific controlled temperature and reaction speed in a nitrogen purged system. Currently, most of the polyols that are used in synthesising PUR are derived from petroleum and natural gas sources ,2. As noVegetable oil, cellulose and sugar are among the bio-based feedstock that have been used in producing PUR ,5. BetweJatropha curcas tree is one of the main industrial crops in Malaysia with a total coverage area of 809 ha  dodecanoate) (DBTDL) (95%), HEMA (IUPAC name: 2-Hydroxyethyl 2-methylprop-2-enoate) and trimethylolpropane triacrylate (TMPTA) were supplied by Sigma-Aldrich, Germany. The bio-based JOL was prepared in two steps namely epoxidation and hydroxylation. This method was adopted from  with sliInitially, JO was mixed with formic acid at 300 rpm at 40 °C until it became homogenous. Then, hydrogen peroxide was added slowly using a dropping funnel and the temperature was raised to 60 °C. In each hour, an oxygen oxirane content test (OOC) was performed based on the ASTM D1652-97 Method A standard. The reaction continued for 4.5 h based on previous literature in order to achieve the maximum value of OOC. The mixture was then cooled and transferred into a separating funnel. The aqueous layer was discarded and the epoxidised jatropha oil (EJO) was washed with distilled water until it achieved a neutral pH level.In the second reaction, a stoichiometric of EJO (10 mol) was reacted with a mixture of methanol (9 mol) and 0.07% diluted sulfuric acid (1 mol). At first, methanol in the presence of the acid catalyst was activated by a heating and stirring process under conditions of 40 °C, 300 rpm for 15 min. Afterwards, the EJO was added into the solution and continuously mixed for 30 min at 65 °C. OOC was conducted to check the disappearance of the oxirane ring during the synthesis process by the titration method. The JOL mixture was cooled and then moved into a separating funnel to remove the aqueous layer. The JOL was washed with distilled water until it was free from acid. The excess water and methanol were removed using a rotary evaporator at a temperature of 60 °C. The JOL was then tested for hydroxyl value (OHV) referring to ASTM D4274-99 Test Method C prior to the isocyanation reaction.w/w) of the total amount of JPUA-TDI.A corresponding amount of JOL: 2,4-TDI: HEMA was calculated based on a molar ratio of 1:1:1. The reaction was accomplished in a four-neck flask complete with a stirrer and condenser in a nitrogen purged system. First, JOL was mixed with DMF at 60 °C with a stirring rate of 350 rpm. Next, 2,4-TDI was added in a dropwise manner within 15 min and the reaction was mixed continuously for 2 h. Then, the temperature was cooled down to 40 °C and HEMA was added into the mixture. Later, the temperature was raised up to 70 °C for 1 h upon complete termination of the reaction of JPUA-TDI. During the reaction, DMF was added into the mixture to control the viscosity of the solution to avoid the gelling phenomena. The amount of DMF was set to be 50% (w/w) of DBTDL was added into the mixture of JOL as a catalyst to initiate the reaction with the IPDI-based isocyanate.The same procedure was repeated for the IPDI-based JPUA with the same NCO/OH ratio. However, 1% (w/w) of the total amount of the formulation. The amount of each component of the formulation is listed in In the JPUA-TDI and JPUA-IPDI-coating formulation, TMPTA and benzophenone were selected as a trifunctional acrylate monomer and photoinitiator respectively. The quantity of benzophenone was set at 4% (The coating formulation was coated on a glass substrate (10 cm × 10 cm × 0.3 cm) using a bar applicator with a thickness of 50 µm. The wet film was exposed under UV radiation  at an energy level of 200 W/cm at a speed of 5 m/min. The film was considered fully cured after nine passes under UV light based on non-tackiness test using a finger (ASTM D1640).The viscosity of the JO, EJO, JOL, JPUA-TDI and JPUA-IPDI were determined by using a Haake Mars Rheometer  at 25 °C. Approximately 1 g of resin was placed on the sample platform for testing. A flat plate spindle (PP 60) was moved on the sample in rotation mode with a gap of 1 mm. The viscosity was measured using plate-plate geometry mode and analysed by Rheo Win software.The colour measurement was performed using a Lovibond Colour Tintometer . The colour recognition was achieved based on matching the similarity of the resin colour with the combination colour filter of red, yellow, blue and neutral.−1 with a resolution of 4 cm−1. This instrument ran an average of 32 scans per sample.The conversion of the functional group during the chemical reactions was analysed using FTIR . It was equipped with an attenuated total reflectance (ATR) accessory with a pure diamond crystal. The reading was in the spectral range of 500–4000 cmThe molar mass of the polymer and its polydispersity index (PDI) were determined by using GPC . Total of 5 mg of sample was diluted in 5 mL THF and injected into three types of column; Styragel HR1, Styragel HR 3 and Styragel HR 5 respectively.Thermal gravimetric analysis (TGA) of the JPUA-TDI and JPUA-IPDI-cured film was conducted using a Netzsch  tester based on ASTM E1131. The samples were run under conditions from room temperature up to 700 °C with a heating rate of 10 °C/min under a nitrogen-purged atmosphere.The hardness of the UV-cured film was measured using a Pendulum Hardness tester . The test was conducted referring to ASTM D4366 with the König damping mode. The data was counted in seconds during the damping time of the pendulum till it totally stopped. Readings were taken in triplicate for each sample and the average value was calculated.A cross hatch adhesion test was done according to ASTM D3359-09 . The kit came complete with a cutter blade, tape, brush and magnifying glass. A 1-mm space cutter blade was chosen based on the coating thickness to prepare the lattice pattern. A piece of 3M Scotch transparent tape was applied on the lattice and pulled off at approximately at a 180° angle. Any dirt was gently removed using the brush and the surface was examined using a magnifying glass. The adhesion score was given based on the removed area of the lattice as described in Static contact angles were examined on the surface of the cured film of JPUA-TDI and JPUA IPDI at 25 °C using an Attension Theta Optical Contact Angle tester . Approximately 7 µL of deionised water was applied on the coating surface using the sessile dropping method. The contact angle readings were measured based on its intersection with the surface within one minute after the deionised water was dropped.The transmittance (ASTM E1348) and haze tests (ASTM D1003) of the JPUA-TDI and JPUA-IPDI cured film were performed using a Haze Illuminant tester . This machine measured both properties simultaneously as a percentage value. All readings were taken three times and the average value was recorded.Two series of JPUA namely JPUA-TDI and JPUA-IPDI were successfully synthesised. The physical properties of the products during stepwise synthesis reaction are reported in Colour measurement is one of the physical properties for oil and its derivatives. Any colour changes provide information on production output during physical treatment and chemical reaction. In this study, the colour of the JO-based resin differed in each reaction step. The colour of JO in its original form was brownish and then changed to light yellow and yellow after reaction of epoxidation and hydroxylation. For the isocyanation stage, the colour of JPUA-TDI was slightly brownish while JPUA-IPDI was visually seen as light yellow. This observation was comparable as reported by  for JPUA−1. A similar trend was observed in the other types of natural oil such as palm [−1. Based on the titration method, the OOC obtained was 4.25 ± 0.08% (−1) and a new broad peak of the OH group was formed at 3435 cm−1. The OHV achieved for JOL was 149.44 ± 0.23 mg KOH/g  bending and amide (-NH) stretching respectively. The peak of carbonyl (C=O) was observed at 3369 cm−1 [−1 which related to the acrylate double bond (-CH=CH2) and vinyl functionality of (CH2=CH-COO-) respectively [The FTIR spectrum during isocyanation of JOL is depicted in 369 cm−1 . The abs369 cm−1 ,16. The ectively . Both JPC = O) was attacked by nucleophilic of oxygen (O-H) from alcohol during the isocyanation process. In 2,4-TDI, the benzene ring acted as an electron withdrawing group via an inductive effect. The negative charge in benzene was then delocalised in the π ring system. This enhanced the positive charge on the carbon of isocyanate (N = C = O) to further undergo a nucleophilic addition reaction with oxygen (O-H) derived from JOL. Therefore, this raised the reactivity and speeded up the reaction during isocyanation [Generally, the reactivity of the reaction depends on the structure of isocyanate being used. The electrophilic carbon of isocyanate (N = yanation .3) groups which bonded to the cyclic ring. This effect reduced the reactivity of the IPDI and slowed down the isocyanation reaction [Apart from that, the steric hindrance effect formed in IPDI because of the existence of three methylene  DMF added during the isocyanation reaction to avoid gelation. The additional solvent decreased the viscosity of the JPUA-TDI and JPUA-IPDI from their actual values.For the viscosity property, the higher crosslinking in each reaction step reflected the longer polymer chain which led to higher viscosity . This trNevertheless, to compare the viscosity only between JPUA-TDI and JPUA-IPDI resins would be considered valid as the success of the reaction was supported by FTIR and GPC data. From TGA analysis is useful in providing information regarding the purity of a compound and its stability temperature during processing. The TGA thermogram and weight loss derivative curves in −1 (-CH=CH2), 815 cm−1 (CH2=CH-COO-) 660 cm−1 (C=C bending) was wiped out after exposure under UV irradiation. This data indicated that the acrylate group had been utilised during the radical polymerisation reaction. This finding matched with other types of acrylate system such as epoxidised soy bean acrylate [In a UV curing system, acrylate is the functional group that is responsible to react with radical species during polymerisation. The radical species was generated by a photoinitiator after being exposed to UV light. Based on the FTIR spectra in acrylate , epoxidiacrylate , epoxidiacrylate  and a waacrylate .The mechanical property tests were conducted on a cured film containing either JPUA-TDI or JPUA-IPDI with corresponding ratio of a TMPTA monomer and benzophenone as a photoinitiator. Initially, benzophenone induced the curing reaction by absorbing the energy from the UV light and became excited to a higher energy level. Next, benzophenone became unstable and experienced a photocleavage reaction and turned into a radical species known as benzoyl radical. Benzoyl radical attacked the carbon double bond (C = C) on the acrylate part which was given by JPUA-TDI, JPUA-IPDI  and TMPTThe hardness of JPUA-TDI and JPUA-IPDI films is presented in The symmetrical rigid structure of the side chain of 2,4-TDI on the JPUA-TDI backbone caused steric hindrance. This effect generated constraints for the benzoyl radical to attack the carbon double bond (C = C) of the acrylate chain during the propagation state of radical polymerisation. Meanwhile, JPUA-IPDI offered a more flexible, asymmetrical aliphatic structure of IPDI side chain with less steric hindrance . This maThe hardness property of the film increased as the ratio of monomer increased because of the high crosslinking polymerisation via hydrogen bonding ,22 betweThe chemical structure of the polymer and its flexibility highly affects the adhesion property. From the result in The JPUA-TDI based film had a better adhesion property than the JPUA-IPDI which matched its lower hardness value . This inThe wettability of JPUA-TDI and JPUA-IPDI-based coating were investigated using the water contact angle as presented in The crosslinking density and flexibility of the molecular chain also affected the surface wettability property ,34. The The optical property of the films was characterised by a Transmittance and Haze test. The transmittance measures the amount of light that passes through a material. Based on Haze is defined as the cloudy appearance of a material because of the light scattering of an imperfect surface. Several factors have been identified to affect the haze property such as poor dispersion, the coating technique, curing method, types of materials and additives and surface treatment.From Two varieties of JPUA based on TDI and IPDI isocyanates have been successfully synthesised. JPUA-TDI had a higher viscosity and molar mass with a broad PDI value compared to JPUA-IPDI resin. Both JPUA-TDI and JPUA-IPDI showed a similar degradation trend under TGA analysis. The JPUA-TDI-based formulation had low hardness but good adhesion compared to the JPUA-IPDI-based formulation. The best adhesion for both JPUA-TDI and JPUA-TDI-based films were at a ratio of 35:65. Both JPUA-TDI and JPUA-IPDI coating formulations owned a good transparency property. It is suggested that both JPUA-TDI and JPUA-IPDI can be used for clear coat coatings such as for windows and for the automotive and construction industry.


Alcohol consumption is associated with different types of illnesses; particularly heavy episodic drinking is one of the risk factors for the disease burden of alcohol intake. The aim of the study was to assess the prevalence of heavy episodic drinking and associated factors in Arba Minch Health and Demographic Surveillance Site (HDSS).p-value of less than 0.10 for bivariate analysis entered into a multivariable logistic regression model to outline the independent predictors of the heavy episodic drinking. To assess the presence of an association between dependent and independent variables, a p-value of less than 0.05 was considered.A community-based cross-sectional study was conducted in 2017 among adult residents of Arba Minch HDSS. Using Arba Minch HDSS database, 3368 individuals were selected by simple random sampling techniques. From WHO STEPS instruments, step one was applied for this study. Variables with a The prevalence of heavy episodic drinking was 13.7% (95% CI: 12.6–14.9). The study has shown that heavy episodic drinking was significantly associated with occupation , wealth index  and 3rd quintiles  compared with 1st quintiles), and climatic zone , highland  compared with lowland). In addition, tobacco use , and khat use [AOR = 4.75; 95% CI: 2.66–8.50) were also associated with heavy episodic drinking among the study participants.More than one in ten adults reported heavy episodic drinking in the study area. Intervention programs that aim to prevent heavy episodic drinking should be designed appropriately for individuals from lower wealth status, and for highlander. Heavy episodic drinking is associated with different types of illnesses including cardiovascular disorders, different forms of cancer, liver cirrhosis, and chronic pancreatitis –5. HarmfIn 2016, the global current drinkers were reported to be 43.0% and for Africans, it was 32.2% among age above 15 years . EthiopiWorld Health Organization (WHO) recommended both the prevention and treatment of harmful use of alcohol as a strategy for reducing its public health impact . For the, khat chewing, and mental stress were included in the questionnaire, which are not a part of the STEPS guideline. Questionnaire from Ethiopia Demographic and Health Survey (EDHS), which was based on the household ownership of productive asset and household characteristics, were used to categorized wealth status of the participants [A community-based cross-sectional study was conducted from April to June 2017 in Arba Minch HDSS. Arba Minch HDSS includes nine Kebeles of Arba Minch Zuria District, Southern Ethiopia. Adult residents (25–64 years) of Arba Minch HDSS were considered as a source population. Pregnant mothers and women who have history of recent delivery up to 8 weeks were excluded from the study. WHO STEPS guideline was followed for calculating the sample size and it was 3368. The sampling frame was obtained from Arba Minch HDSS and a simple random sampling technique was implemented to select the study participants. For the extraction of the sampling frame, sex, date of birth, and individual and household identifications were used. The sampling frame was stratified in to eight groups (based on sex and age categories) and STATA version 14 was used for selecting the study participants from each stratum. The WHO STEPS instruments and data collection procedures were adapted for data collection. Step one of the STEPS approach was applied for this study, which depends on the questionnaire. The questionnaire was designed to obtain core data on socio-demographic information, tobacco and alcohol use, and physical activity . Variablicipants . Self-Reicipants . The inticipants , 21, 22.icipants .p-value of less than 0.10 in bivariate analysis and variables with significant importance were entered into a multivariable logistic regression model to outline the independent predictors of the heavy episodic drinking. To assess the presence of an association between dependent and independent variables, a p-value of less than 0.05 in the final model was considered. For the assessment of multicollinearity, variable inflation factors were used and non-collinear variables were used. The Hosmer-Lemeshow test was checked to assess the goodness-of-fit model and the P-value was 0.515.EPIData version 3.1 statistical software was used for data entry (single data entry) and the data were exported to STATA version 14 for data management and analysis. Wealth index was computed using a principal component factor analysis and grouped into five quantiles. Variables from the STEPS tool was generated in accordance with the manual . AltitudA total of 3346 adults have participated in the study, making a response rate of 99.3%. The mean (SD) age of the study participants was 44.611.2) years. Half of the participants were female (50.0%) and farmers (53.2%). Majority of the participants had no formal education (69.8%), married (87.9%), from Gamo ethnic background (81.1%) and rural residents (83.7%). A significantly higher proportion of heavy episodic drinking was observed among the Orthodox religious followers (Table 1.2 yearsNearly 20% of the study participants were current tobacco consumers. Most (64.3%) of the study participants involved in high physical activity. Nearly 2% of the participants chew khat and 4% had severe mental stress levels (Table Nearly 40% (95% CI: 38.6–41.9) of the participants reported that they have consumed alcohol in their lifetime; of whom 80.1% (1079) have consumed alcohol in the past 12 months. This means that from the total participants, 32.3% (95% CI: 30.7–33.9) took alcohol within the past 12 months. From those who took alcohol last year, 14.0% (151), 39.5% (426) and 46.5% (502) took alcohol at least daily, at least once per week and at least once per-month, respectively.From the total participants, 27.4% (95% CI: 25.1–29.9) had consumed alcohol within the past 30 days. Nine hundred study participants recalled the frequency of having alcohol at least one standard drink in the past 30 days and the mean (SD) was 3.9(3.3). The prevalence of heavy episodic drinking was 13.7% (95% CI: 12.6–14.9).Based on bivariate analysis, the odds of heavy episodic drinking were significantly higher among males compared to females, and older age groups especially 35–44 and 55–64 compared to 25–34 years old. In addition, significantly lower odds were observed among those who attended higher education especially primary education compared to no formal education, and urban residents compared to rural.Based on multivariable analysis, the odds of heavy episodic drinking were significantly lower among daily laborer  and housewives  compared to the farmer. The probability of having heavy episodic drinking was lower among participants living in higher wealth quantile households. Significantly lower odds of heavy episodic drinking were observed among 2nd and 3rd quantile, which was nearly by half for 2nd quantile  and one third for 3rd quantile . For those who live at midland  and highland , the probability of having heavy episodic drinking increased compared with lowlands. Among current tobacco users and Khat chewers, the probability of consuming heavy episodic drinking was more than four times   is a chewable fresh-leave used as stimulant commonly in East Africa. It contains amphetamine-like stimulatory, which is a closely similar effect with cathinone [Khat (athinone , 43. In athinone –47. A stathinone . Khat chathinone .Even if the study used the STEPS guideline, which makes it easy to compare with studies conducted based on a similar method and definition of heavy episode drinking, there are limitations. The data were collected using interview including alcohol intake. This self-reported information regarding alcohol intake use may be subjected to recall errors. In addition, it is culturally unacceptable to openly acknowledge drinking habits for unemployed youth and housewives. Most of the alcoholic beverages were made locally, which does not have a standard alcoholic content and with a significant difference in content to estimate the standards , 50. BecMore than one in ten adults were heavy episodic drinkers in the study area. This showed that heavy episodic drinking attracts attention to the urgent need to develop more effective prevention strategies. Occupation, economic status and altitude and substance use including tobacco and khat are factors associated with heavy episodic drinking among the adult population. Intervention strategies for reducing the prevalence of heavy episodic drinking need to address the population who chew khat, use tobacco and live in highlands. It is indicated that the impact of harmful lifestyle, including heavy episodic drinking, is disproportionately affect the deprived population , 52. Int


We sought to describe the surgical techniques required in the ab-interno method to implant subretinal prostheses in mini-pigs and suggest tips to facilitate optimal outcomes. During vitrectomy, the use of valved trocar cannulas was essential to stabilize the detached retina and implanted chip. As a first step in retinal detachment, a 23-gauge cannula with very small amount of viscoelastic material was used to establish the retinal hole and promote retinal detachment. Then, balanced salt solution was applied to increase the retinal detachment and diathermy was used to make opening for subretinal prosthesis. For easy positioning of the subretinal prosthesis, a curved laser probe was adopted when handling the subretinal prosthesis under the retina. After surgery, the sclerotomy sites were tightly sutured to prevent silicone oil leakage. Without special equipment, such as a 41-gauge tip, retinal detachment could be induced easily, while the prosthesis was also successfully inserted and manipulated under the retina without an iatrogenic retinal tear. Two weeks after the operation, the oil fully occupied the intraocular volume without leakage. The subretinal prosthesis remained stable without complication. Understanding the principle of the ab-interno method and considering several tips for improving surgical access may help to enhance surgical success rates of subretinal prostheses implantation. Each device requires a different surgical approach for implantation because of its design and intended location10. Recently, PRIMA implant has been introduced to the market as a wireless subretinal micro photovoltaic chip and can be implanted via an ab-interno approach17. Considering interim clinical trial results from Europe and relative ease of the surgery18, development and implantation of this type of retinal prosthesis is likely to rapidly increase the need for surgeons to perform the surgery more safely and comfortably29. However, current methods for subretinal surgery as well as ab-interno subretinal implantation have not been widely taught to current-generation retinal surgeons, with subretinal surgical approaches being more widely discussed and published on in the late 1990s and early 2000s31. Although ab-interno surgery for subretinal implantation is easier than ab-externo surgery32, this surgical procedure still requires an experienced operator and involves the conduct of inconvenient procedures using additional instruments, such as connecting a 41-gauge cannula to the vitrectomy machine.In degenerative retinas, such as those with retinitis pigmentosa or dry age-related macular degeneration, visual loss is the result of damage to photoreceptors. In advanced stages of such retinal degeneration, surgical implantation of retinal prostheses has been the foremost commercially available treatment optionHere, we presented an ab-interno method for the induction of retinal detachment and manipulation of the subretinal prosthesis and offer several tips focused on reducing surgical difficulties.33. Three-port, 23-gauge vitrectomy  was performed with an indirect BIOM lens . Three ports were prepared by inserting trocar cannulas into the sclera at 3 mm from the limbus on the ventromedial, ventrolateral, and dorsomedial sides, respectively. The vitreous was removed using a vitreous cutter while continually supplying balanced salt solution (BSS) . Anterior capsule-saving lensectomy was also performed.During vitrectomy, valved trocar cannulas were used to stabilize the intraocular volumeA small hole was made by pressing the retina lightly with a 23-gauge cannula of viscoelastic material at the superonasal peripheral retina, and less than 0.1 cc of viscoelastic material was injected into the retinal hole to induce a tiny focal retinal detachment. Next, the cannula with BSS was inserted into the subretinal cavity and the BSS was gently injected to increase the size of the retinal detachment Fig.  online. Diathermy was used to create a hole to insert the subretinal prosthesis under the retina and the hole was gradually widened by about 4.5 mm  were placed under general anesthesia by the intravenous injection of alfaxalone  into the marginal auricular vein following premedication with a subcutaneous injection of atropine (0.05 mg/kg) and an intramuscular injection of xylazine  and azaperone (4 mg/kg). Following the induction of general anesthesia, each eye was irrigated with 5% povidone iodine and draped for surgery.All procedures adhered to the Association for Research in Vision and Ophthalmology (ARVO) Statement for the Use of Animals in Ophthalmic and Vision Research . Approval for this study was obtained from the Institutional Animal Care and Use Committee of Korea University’s College of Medicine.37. These electrodes were combined with a 40-μm-thick polyimide film, using glue. The combined chip was coated with 3-μm-thick parylene-C to assure the biocompatibility. The overall chip size was 4.5 mm × 5 mm  for the transparent base of the electrodes. The detailed fabrication procedures are described elsewhereSupplementary Video 1.Supplementary Video 2.Supplementary Video 3.Supplementary Video 4.Supplementary Video 5.Supplementary Video 6.Supplementary Video 7.Supplementary Video 8.Supplementary Video 9.Supplementary Video 10.Supplementary Video 11.


Alcohol labels are one strategy for communicating health information to consumers. This study tested the extent to which consumers recalled alcohol labels with national drinking guidelines and examined the impact of labels on awareness and knowledge of the guidelines.A quasi-experimental study was conducted in two jurisdictions in northern Canada examining the impact of labels on the following outcomes: unprompted and prompted recall of the drinking guideline label message, awareness of the drinking guidelines, and knowledge of the daily and weekly recommended drink limits. The intervention site applied labels with national drinking guidelines, a cancer warning, and standard drink information to alcohol containers in its liquor store, whereas the comparison site did not apply these labels. In total, 2,049 cohort participants in both sites were recruited to complete surveys before and at two time points after the intervention. Changes in outcomes were examined using generalized estimating equations.After the intervention, unprompted and prompted recall of the drinking guideline label message increased more in the intervention versus comparison site . Awareness of the drinking guidelines increased 2.9 times more in the intervention versus comparison site . In addition, knowledge of the daily and weekly drink limits increased 1.5 and 1.4 times more in the intervention versus comparison site, respectively .Enhanced alcohol labels get noticed and may be an effective population-level strategy for increasing awareness and knowledge of national drinking guidelines. These sites were selected because Yukon and Northwest Territories are the only two jurisdictions in Canada that require post-manufacturer alcohol labels to be applied to most alcohol containers sold in government-run retail liquor stores. Since 1991, labels in both jurisdictions warn consumers about drinking while pregnant, with an additional message in Northwest Territories cautioning against drinking and driving or operating machinery and that alcohol may cause health problems . In addiTwo waves of surveys were scheduled in the intervention and comparison sites, 4 months before and 8 months after the intervention labels were implemented. The intervention labels with the cancer warning and national drinking guidelines were applied to alcohol containers in the intervention site starting November 20, 2017, with the standard drink label to be introduced shortly after. Liquor store staff were instructed to apply the intervention labels upright and to avoid covering manufacturer labels on the containers.However, 1 month into the 8-month intervention period, the government in the intervention site paused its participation in the study because of pressure from Canada’s alcohol industry and stopped applying labels . Based oA prospective cohort of adult drinkers was recruited in Wave 1 by trained research assistants (RAs) as they exited the liquor stores in both sites, using a standard intercept technique of approaching every person that passed a pre-identified landmark in the liquor store. Participants were asked to complete a screener on a 10-inch tablet to identify eligibility status. Eligible participants provided consent and completed the Wave 1 survey on the tablet without RA assistance. In Waves 2 and 3, participants who provided their contact information were emailed survey instructions, a unique survey link, and an e-transfer as remuneration. In addition, due to attrition, the sample was replenished using Wave 1 recruitment protocols in both sites , residents of either the intervention or the comparison city, and, at the time of recruitment, were current drinkers , had purchased alcohol at the liquor store, and did not self-report being pregnant or breastfeeding.To assess “noticing” the alcohol labels, participants were asked whether they had seen any warning labels on bottles or cans of beer, wine, hard liquor, coolers, or ciders. Responses were dichotomized as “yes” and “no/ don’t know.” The measure at Wave 1 was anchored with 6 months prior, the measure at Wave 2 from November prior to follow-up, and Wave 3 from April prior to follow-up.Among those that indicated “noticing,” participants were first asked an unprompted open-ended question to indicate what messages they had seen on the warning labels. Subsequently, to assess prompted recall, participants were shown a list of possible label messages and were asked to select all messages that they saw on alcohol containers. Response options included alcohol and cancer, low-risk drinking guidelines, number of standard drinks in bottles or cans, alcohol may be an addictive drug, alcohol and liver disease, alcohol and trauma, alcohol and fetal alcohol spectrum disorder, and drinking alcohol and driving a car or operating machinery. Both recall measures were anchored similarly to the “noticing labels” measure. For the unprompted recall measure, an RA blinded to experimental conditions coded each response. A second coder reviewed ambiguous responses and discussed them with the first coder to reach consensus. Any reference to drinking guidelines or mention of cancer was coded as recall of national drinking guidelines and recall of the cancer label, respectively.Awareness of the national drinking guidelines was measured by the question, “Were you aware of Canada’s Low-Risk Drinking Guidelines before today?” Responses were dichotomized as “yes” and “no/don’t know.”Knowledge of sex-specific daily recommended drink limits was measured by the question, “What is the daily limit of ‘standard drinks’ recommended for males/females (depending on identified sex) in Canada’s Low-Risk Drinking Guidelines?” Participants were asked to enter the number of standard drinks per day. Consistent with the language used in Canada’s Low-Risk Drinking Guidelines  and on tstrongly disagree to 5 = strongly agree, with don’t know and prefer not to say as options.Participants were asked if cans and bottles of alcoholic beverages should be labeled with Canada’s low-risk drinking guidelines (LRDG). Responses were given on a 5-point Likert scale from 1 = Sociodemographic measures included age, sex, ethnicity , education , and income . (Income is in Canadian dollars.)Health literacy was assessed using the Newest Vital Sign assessment tool, a short validated measure to identify health literacy levels , and resGeneralized estimating equation (GEE) models using a binomial distribution with logit link function were used to examine the impact of the intervention labels on five outcomes: unprompted and prompted recall of the drinking guidelines label message, awareness of the national drinking guidelines, and knowledge of daily and weekly drink limits. GEE models can account for a mix of within-subject correlation that arises from the cohort participants being asked the same questions over multiple survey waves, in addition to accounting for the replenishment sample . DiffereThe final sample consisted of 2,049 unique participants, providing 3,277 observations. Response rates in the intervention and comparison sites were 8.9% and 8.0%, respectively , with 53Unprompted recall of the drinking guidelines label message increased 3.1 times more between Waves 1 and 2  and 10.8 times more between Waves 1 and 3 , and 7.0 times more between Waves 1 and 3  and 1.5 times greater increase between Waves 1 and 3 , and 1.6 and 1.3 times more likely to know the daily  and weekly  drink limits, respectively, compared with those who did not recall the cancer message.The majority of participants were neutral to strongly supportive of applying labels with national drinking guidelines on alcohol containers in both the intervention  and comparison  sites . See SupAlcohol drinking guidelines are used internationally to provide evidence-informed recommendations of upper drink limits for low-risk alcohol consumption. To adhere to these drinking guidelines, consumers must be aware of and understand the recommended limits. International research indicates that public awareness and knowledge of drinking guidelines is lower than 50% in most jurisdictions . ExpertsModest increases in knowledge of the daily and weekly drink limits were also observed following exposure to enhanced alcohol labels in the intervention site, both in the shorter term (Waves 1 to 2) and over the full study period (Waves 1 to 3). One explanation for the modest differences in changes in knowledge between sites is that knowledge of the daily and weekly guidelines increased in both the intervention and comparison sites over the study period. Increases among participants in the comparison site not exposed to the label intervention are likely because the study received national and international media coverage following the alcohol industry’s interference in the study . AlthougNevertheless, the results of the current study demonstrate the unique benefits of labels for increasing awareness and knowledge of national drinking guidelines. In addition, the study provides evidence that recalling the cancer label message enhanced the intervention impact on LRDG outcomes, highlighting the potential synergistic effects of the rotating labels. Previous population-based interventions that were intended to increase awareness and knowledge of drinking guidelines focused on longer multicomponent information-based campaigns, with various levels of success. Two of these campaigns, one conducted in the Canadian province of Quebec and the other in Denmark, reported increases in knowledge of drink limits following much longer-term and well-resourced campaigns . HoweverPrevious studies have highlighted the association between knowledge of drinking guidelines and lower levels of alcohol use , but theThe study has several limitations. First, considering that the intervention was interrupted and shortened due to the alcohol industry’s interference and the small sample sizes in both sites, the effects of the labels might have been stronger if these limitations had been resolved and the study had been implemented as planned. Next, the study sample was not representative of the site populations, as participants were recruited from liquor stores in city centers using non-probability-based methods, limiting generalizability. In addition, the national media coverage of the alcohol industry’s interference in the study may have contaminated the comparison site by exposing information about the study and intervention, particularly the alcohol label messages. Finally, due to very low rates of unprompted recall in the comparison group, DID results lacked precision and produced wide CIs. However, the low rates of recall and awareness of the national drinking guidelines before the alcohol label intervention also provide a strong rationale for enhanced alcohol labels.Alcohol labels with national drinking guidelines, standard drink information, and a cancer warning may be an effective population-level strategy for increasing awareness of drinking guidelines and knowledge of drink limits, a stated goal of international alcohol control efforts . This stThe authors would like to acknowledge all the RAs who helped collect the data, as well as the liquor control boards, health and social services, and community partners in Yukon and Northwest Territories for their commitment and support in developing and executing this research. Special thanks also go to Mark Petticrew and Melanie Wakefield for their expertise and guidance.