The measurement of static vertical deflections on bridges continues to be a first-level technological challenge. These data are of great interest, especially for the case of long-term bridge monitoring; in fact, they are perhaps more valuable than any other measurable parameter. This is because material degradation processes and changes of the mechanical properties of the structure due to aging (for example creep and shrinkage in concrete bridges) have a direct impact on the exhibited static vertical deflections. This paper introduces and evaluates an approach to monitor displacements and rotations of structures using a novel laser and video-based displacement transducer (LVBDT). The proposed system combines the use of laser beams, LED lights, and a digital video camera, and was especially designed to capture static and slow-varying displacements. Contrary to other video-based approaches, the camera is located on the bridge, hence allowing to capture displacements at one location. Subsequently, the sensing approach and the procedure to estimate displacements and the rotations are described. Additionally, laboratory and in-service field testing carried out to validate the system are presented and discussed. The results demonstrate that the proposed sensing approach is robust, accurate, and reliable, and also inexpensive, which are essential for field implementation. In the last 60 years there has been a spectacular increase in bridge heritage issues. While these infrastructures have provided significant benefits to society, an increasing amount of resources are needed for their maintenance in order to ensure an adequate level safety and comfort. Within the maintenance tasks, visual inspection is an essential activity, ultimately enabling efficient resource use. Challenges with this activity have been associated with the need for a significant use of human resources combined with low efficiency. Additionally, in many cases inspection results show a notable level of subjectivity, that is, in most cases the bridge inspection results depend on the skill and experience of the technicians who performed the inspection.accurate, with the ability to measure small displacement changes;robust, to withstand varying temperature and humidity and operate under harsh conditions;reliable, producing accurate and repeatable measurements; andinexpensive, due to the large number of bridges to be monitored.On the other hand, there has been enormous development of sensor technology, increasing their quality and, overall, dramatically reducing their cost, which has allowed their use for bridge monitoring applications. Bridge monitoring becomes a useful tool, alongside an inspection with its conventional procedures, to quantify the actual state of the bridge and its evolution over time. Using the monitoring results it is possible to implement better bridge preventive maintenance plans, which can be also specific for each structure. Among the many parameters that can be monitored on a bridge, vertical deflection is perhaps the most useful one, as it can be directly related to the in-service behavior of a bridge. First, all international standards specify the maximum allowable deflection of a bridge under service loads to ensure its functionality ,2. In adSeveral technical solutions exist on the market such as: displacement transformers , laser distance meters, acoustic and electromagnetic interferometers, total station theodolites, global positioning system (GPS)-based systems, geophones, accelerometers, etc. However, none of them are able to fulfill all the requirements previously described.In recent years, a novel set of solutions has emerged: video-based sensors. This promising and quickly evolving technology has been driven by the continuous improving of the features of digital video cameras resulting in rapidly decreasing costs. Today it is possible to get a commercially-available 4K video camera at accessible prices. In addition, the development and wide availability of digital image processing (DIP) software, initially developed for applications very different from bridge monitoring, allows one to simplify post-processing tasks to extract the required information. While this is a promising technology, it is not a technology mature enough to be widely implemented for bridge monitoring purposes. Several challenges still exist with this technology before it can be implemented in the field. The first one is concerning resolution and accuracy, which have to be further improved in order to reach a level of, for instance, an LVDT. The second one is the simplification of post-processing tasks. A video record is usually a large file and contains a significant amount of excessive information with only a small portion of it being useful. In order to be able to monitor a structure in real time by analyzing a video record, the ability to post-process many frames per second  is critical.In most of the research published up to date, the video camera is placed away from the bridge on a fixed location. Typically, the bridge is equipped with one or several targets. The movement of these targets is obtained through the comparison of individual video frames ,6,7,8,9.A relevant amount of the research published uses video-based sensors to measure the dynamic response of structures, that is, natural vibration frequency and damping ratio, among others. Also, the measure is carried out during short periods of time on the order of seconds or minutes. The results have been compared to accelerometers and/or LVDT ,18,19,20Recently, some interesting work has been carried out to measure inclination, alone or in combination with displacements, using lasers and videos ,22,23. THowever, this body of work is a useful starting point for the development of a video-based technology capable of capturing static and slow-varying displacements over long periods of time. Only a few number of researchers have documented the monitoring of static vertical deflections over a period of days or weeks .It is worth highlighting in more detail the research performed by Zhao et al. ,26. In tTo the best of the authors’ knowledge, none of the solutions developed to date are capable of tracking a fixed and a moving reference within the field of vision of the video camera simultaneously. This paper introduces a novel sensing approach to monitor displacements and rotations on bridges and structures by combining a laser beam, a video camera, and LED lights. This solution substantially improves the approach proposed by Zhao et al. ,26, elimThe proposed laser and video-based displacement transducer (LVBDT) is composed of two main components: the fixed part and the movable part, as illustrated in The fixed part is placed at a non-moving location and to remain fixed at all times. It is composed by a support fixture holding two laser emitters. The laser emitters used in this research are green dot lasers with a wavelength of 532 nm, output power 5 mW, class IIIA and a beam divergence of 1 mrad.The movable part is placed on the structure and moves jointly with it. It is composed of a video camera and a measurement panel placed on a support fixture. The video camera used in this research was a Lumix DMC-G80  with 16 MP and image stabilization, type 5-axis/5-stop, Dual IS, with a recording speed of 60 fps and an optical zoom of 12–60 mm f/3.5–5.6. The video camera was not connected to a computer, although this is an option that could be implemented.The measurement panel is made of transparent methacrylate with length × height = 300 mm × 200 mm and a thickness of 5 mm. On the backside, a white paper sheet was added to make the measurement panel translucent. Additionally, the panel is equipped with three red LED lights a.xd and yd corresponding to the distances between the LED lights are constant and known. The measurement panel should be placed orthogonally to the video camera. Additionally, the zoom of the video camera should be in its most open position in order to minimize the fish eye effect. The field of vision of the video camera should be completely inside the measurement panel and it should include the five previously mentioned references. When movement of the target occurs and, in consequence, the same movement of the measurement panel, the fixed references on it (laser dots) remain fixed, while the movable references (LED lights) move. However, the record of the video camera will show, in the most general case, that both fixed and movable references move . In the desired case the video camera and the measurement panel move jointly and the record of the video camera will show that the fixed references move while the movable references do not move.The two laser beams project dots on the measurement panel on the opposite side of the white sheet. Inside the field of vision of the video camera there are five references, which are, the three red LED lights and the two green laser dots a. The thAn ideal measurement system must be robust; otherwise it cannot be used on real structures and for long-term monitoring. The robustness of our system depends, among others, on the laser device. The market provides laser pointers able to withstand environmental conditions and with high pointer stability. If necessary, the laser device can be protected using a cover with a transparent window.The system can monitor displacements and rotations in plane with the measurement panel plane. Movements and rotations out of the measurement panel plane cannot be captured.The recommended range for the laser emitters used in this study is below 30 m in order to obtain a laser dot diameter below 30 mm. When the distance between the fixed and the movable reference is larger, low divergence laser emitters should be used, with a divergence of 0.3 mrad or less. Additionally, a greater measurement panel should be used, in order to ensure that the laser dots remain inside the measurement panel during the entire monitoring process.Next, the step by step numerical procedure to analyze the video data is described in detail.First, the video camera records the five references previously explained, i.e., the three LED lights and the two laser dots and many other useless information. The video is recorded using an appropriate frame rate, e.g., at a speed of 60 fps for slowly-varying displacements, or at high speed using special video cameras when vibrations are to be captured. The possibility to record time-lapse videos is interesting, especially for long-term monitoring and slow movement. As explained before, the field of vision of the video camera is inside the measurement panel. Therefore, the videos include three distinct colors: white, red, and green, which simplifies the post-processing of the data. The recording file of the video camera, in AVI, MPEG, MOV, WMV, or similar format is, first, decomposed into a sequence of images or frames. In this case the MATLAB software  was used. Once all frame files are obtained, the post-processing procedure is applied to each individual image. When the video is recorded in UHD, each frame has 3840 × 2160 pixels. With this current setup, the field of vision is governed by the size of the measurement panel (300 × 200 mm), which results in a pixel size of approximately 0.08 mm.Although it is expected that the video camera remains perpendicular to the measurement panel during all the measurement time, a misalignment may occur due to unexpected actions. In consequence, it is necessary to consider this event and to include a first step in the computational procedure to correct it.Neither displacement nor rotation of the frame are required, since both the fixed and the movable references are inside the frame. Additionally, it is not necessary to re-scale the frame, because the physical distance between the LED lights is known (this is intrinsic information of the sensor) and the ratio between the distance between LED lights in pixels and in mm is obtained in each frame, as explained later. In consequence, the only correction to be applied is the homography transform ,29,30,31The second step is to identify, in each frame, the pixels belonging to the five references previously explained, i.e., the three LED lights and the two laser dots. To achieve that, it is necessary to filter the frames, in order to delete any unnecessary information and, thereby, reduce the size of the frames.One of the main advantages of the solution shown is that the references are light-emitters, which implies that it is able to work under variable and changing natural lighting conditions, including night. To validate this assumption, the performance of the LVBDT was evaluated under three significantly different scenarios: during a sunny day, at night, and with the presence of a shadow on the measurement panel.All frames were subjected to a threshold color procedure. In this case, the thresholding method proposed by Huang and Wang  was usedAs can be seen in N-row, 5-column matrix where N is the total number of frames in the video. The first and second columns include the X and Y coordinates of a pixel, respectively, and columns three to five include the RGB color values. Each row is associated with one specific pixel in a frame. The matrix is identified using the time of the frame, which is (n − 1)/t, where n is the number of the frame and t is the time interval between frames (or inverse of the frame rate). Next, the pixels belonging to the five different references are identified and grouped. To do so, color range and proximity criteria are used. A set of color-number thresholds are defined. One color-number threshold value is defined for the laser dots and the other one for the LED lights. These thresholds are the same for all frames. The result are five refN-row, 2-column matrices, where refN is the number of pixels belonging to each reference point, i.e., LED or laser dot. The rest of the pixels are deleted.Next, each frame is transformed into an The next step is to obtain the coordinates of the center of gravity of each reference. Procedures to achieve that are available and described in the literature ,36,37,38ith-frame, each row includes the X and Y coordinate values of the center of gravity of each of the five references, which are the LED lights P1,i, P2,i, and P3,i and the laser dots L1,i and L2,i:At this point, all the information provided by a frame is concentrated in a 5 × 2 matrix and associated with the time of the frame. For the X-Y coordinate system of the frame to the X’-Y’ coordinate system of the reference points P1,i, P2,i, and P3,i , including translation and rotation, from the and P3,i b. The reNext, conversion factors are applied to the matrix shown in Equation (4), in order to convert pixel coordinates to physical coordinates:The matrix is now defined as follows see :(7)[0dx0Finally, the absolute values for horizontal distance, vertical distance and inclination angle are defined for each frame according to the following expressions:In this case, “absolute values” refers to the values relative to the beginning of the measurement.i-th frame there is, in a general case, a movement of all references, both the fixed and movable ones. In fact, a movement of the movable references P1,i, P2,i, and P3,i are only observed if, during the record, a relative movement between the video camera and the measurement panel occurs. However, even in this case and since the references P1,i, P2,i, and P3,i define an intrinsic coordinate reference and L1,i and L2,i are, in fact, fixed references, it is possible to define the real movement of the target, through the variation of the coordinates of L1,i and L2,i referred to the local axis X’-Y’, according to the following expressions and illustrated by Between the 1st and the One of the main advantages of this proposed approach, and also its main novelty, is that every frame includes both the fixed and the movable references. In consequence, the measurement is independent of the position of the video camera. The system is capable of capturing both the horizontal and vertical movement as well as the rotation of the target, all of them contained in the measurement panel plane. The range of the measurement depends on the dimensions of the measurement panel and the resolution depends on the quality of the video camera. Another relevant advantage is that the post-processing is simple and computationally inexpensive, and can thus be performed on a regular desktop or laptop computer. The procedure supports every recording speed (from ultrahigh speed to time lapse recording) and every video camera resolution (from 720 p to the new 8K).This solution provides sub-pixel accuracy for displacements, both horizontal and vertical. For the case of rotations, it is less accurate, since it is inversely proportional to the distance between laser dots.θ), where θ is the angle between the laser beams and the measurement panel. Consequently, it is recommended that the laser beams impact perpendicular to the measurement panel.It is not necessary that the laser beams should impact perpendicular to the measurement panel as long as the panel moves only within its plane. However, if out-of-plane movements and/or rotations of the panel are expected to occur , the lack of orthogonality between laser beams and measurement panel introduce non-real movements. These are proportional to cos, which served as the reference measurement. The movable part of the LVBDT was placed on a horizontal steel beam connected to a dynamic tension—compression actuator, model MTS 244.51 , with a capacity of ±1000 kN. The actuator had a built-in LVDT with a range of 250 mm and an error < 1% over its range. The actuator was connected to an ultra-rigid frame. The fixed part of the proposed LVBDT was placed on the floor of the lab, at a distance of 15 m . The disDuring the test, the piston of the hydraulic actuator was moved down slowly, remaining at this position for several seconds and, finally, it was moved down up to its initial position. The maximum displacement was 20 mm. The displacement rate was 0.2 mm/s. During testing, the vertical deflection was measured and recorded using both the LVDT of the hydraulic jack and the proposed LVBDT. In this case, although the recording speed of the video camera was 60 fps, only 1 fps was used for post-processing. A comparison of the obtained displacements from both sensors are shown in As can be observed in An in-service load test was performed in order to evaluate the response of the proposed LVBDT under realistic field conditions. The tested structure was the Loiola Station Bridge located in the City of San Sebastian, Spain and is an 11-span continuous composite steel-concrete bridge. The span lengths are 50.4 + 21.6 + 24.0 + 6 × 21.6 + 24.0 + 26.4 m corresponding to a total length 277.2 m. The cross section includes to steel box girders connected with transverse I-beam girders. Both the box and the I-beam girders have an in-situ concrete slab of 0.25 m thickness, as shown in During the load test, among other parameters, vertical deflection at the mid-span cross section of Span 1 was measured a. These During the load test, several trials were carried out by passing a train over the deck from Abutment 1 to Abutment 2 at different speeds (from low to high). Both LVDT and LVBDT recorded the variation of the vertical deflection of the mid-span cross section over time. Similarly to the lab experiment, although the recording speed of the video camera was 60 fps, only 1 fps was post-processed. A comparison of the obtained displacements from both sensors for one select trial are shown in As can be observed in To date, long-term monitoring of vertical bridge deflections is a technological challenge not well solved. The different technical solutions that can be found on the market only partially address the requirements, especially for the case of large, tall and/or very stiff bridges, or for the ones located in remote places. Hence, an accurate, robust, reliable, and inexpensive solution is needed.This paper presents a novel sensing approach to measure the displacements and rotations in bridges and structures using laser beams, LED lights, and a digital video camera, referred to as laser and video-based displacement transducer (LVBDT). This solution has been especially designed for the long-term monitoring of slowly varying displacements acquired during any time of the day. The LVBDT overcomes some of the limitations shown by the previous solutions. The main novelty is that, inside the field of vision, there are both the fixed and the movable references. In consequence, it is not necessary that the video camera remains fixed or moves jointly with the target; in fact, the position and/or the movement of the video camera during the monitoring has no impact on the measurement. Another advantage is the complete insensitivity to changing lighting conditions, which can be a significant problem for other contemporary video-based approaches. Contrary to other video-based approaches, the camera is located on the bridge, hence allowing to capture displacements at one location.This paper describes the proposed sensor and the computational procedure to obtain the displacements and rotations. The post-processing scheme is simple and computationally inexpensive, and can be performed with off-the-shelf desktop or laptop computers. The laboratory experiment and in-service field test demonstrate the promise of the proposed approach. The differences between the proposed LVBDT and LVDT was within ±2%, which is acceptable for bridge deflection measurements. Future work will look at improving the computational approach, developing an integrated prototype, and evaluating the solution for vibration measurements.A Spanish patent (Patent No.: P201730410) has been submitted and is currently pending .


Because maternal mortality is a rare event, it is important to study maternal near-miss as a complement to evaluate and improve the quality of obstetric care. Thus, the study was conducted with the aim of assessing the incidence and causes of maternal near-miss.A facility-based cross-sectional study was conducted in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. All maternal near-miss cases admitted to the selected hospitals during the study period were prospectively recruited. World Health Organization criteria were used to identify maternal near-miss cases. The number of maternal near-miss cases over one year per 1000 live births occurring during the same year was calculated to determine the incidence of maternal near-miss. Underlying and contributing causes of maternal near-miss were documented from each participant’s record.During the one-year period, there were a total of 238 maternal near-miss cases and 29,697 live births in all participating hospitals, which provides a maternal near-miss incidence ratio of 8.01 per 1000 live births. The underlying causes of the majority of maternal near-miss cases were hypertensive disorders and obstetric hemorrhage. Anemia was the major contributing cause reported for maternal near-miss. Most of the maternal near-miss cases occurred before the women’s arrival at the participating hospitals.The study demonstrated a lower maternal near-miss incidence ratio compared to previous country-level studies. The majority of the near-miss cases occurred before the women’s arrival at the participating hospitals, which underscores the importance of improving pre-hospital barriers. Efforts made toward improvement in the management of life-threatening obstetric complications could reduce the occurrence of maternal near-miss problems that occur during hospitalization. The improvement of maternal health has made slow progress in most of the sub-Saharan African countries . AccordiBecause there were no uniform criteria for the identification of near-miss cases and no standard definition for maternal near-miss until 2009, a heterogeneous estimate of rates was observed in different published literatures around the world. For instance, the rate ranged between 0.14% and 0.75% in some of the high-income countries –13, it rWorldwide, hypertensive diseases of pregnancy, obstetric hemorrhage, sepsis, anemia and obstructed labor/dystocia have been identified as the major causes of maternal near-miss ,14,24–26Ethiopia, as in many developing countries, has a high rate of maternal mortality. According to the 2011 Ethiopian Demographic and Health Survey (EDHS), the maternal mortality ratio (MMR) of the country was 676 per 100,000 live births, and the 2016 EDHS recorded 412 deaths per 100,000 live births ,28. An eThe Federal Ministry of Health of Ethiopia is striving to reduce the rate of maternal mortality of the country. Actions taken so far include organizing and mobilizing the Health Development Army at all levels to promote behavioral change, the distribution of ambulances to all districts of Ethiopia, the provision of free maternity services at different health care levels, the training of human resources and equitable placement of health professionals in health facilities, and the provision of adequate drugs, medical supplies, and equipment . DespiteThe study was conducted in five selected public hospitals of Addis Ababa, Ethiopia from May 1, 2015 to April 30, 2016. The hospitals were selected based on the number of deliveries they managed per year. Because most critical maternal cases are referred to a hospital known to provide better care, the presence of an Intensive Care Unit (ICU), maternity ward, blood transfusion service and facilities for caesarean section (CS) were also considered in the selection of hospitals. Hence, Tikur Anbessa, St. Paul’s Hospital Millennium Medical College, Zewditu Memorial, Yekatit 12, and Gandhi Memorial Hospitals were selected for the current study. Tikur Anbessa Hospital is the largest referral and teaching hospital in Ethiopia and is operated under the Ministry of Education of Ethiopia. St. Paul’s Hospital Millennium Medical College is the largest referral and teaching hospital among those operated under the Federal Ministry of Health. However, the Gandhi Memorial, Yekatit 12 and Zewditu Memorial Hospitals were among the six governmental referral and teaching hospitals that are managed under the Addis Ababa Administrative Health Office. Together, the five hospitals were responsible for a total of 29,697 live birth deliveries during the year in which this study took place. Apart from Tikur Anbessa Hospital, which received very critical cases from different part of Ethiopia, the hospitals are comparable in terms of the patients they receive for care and treatment .A facility-based cross-sectional study design was used to address the objective of the current study.All women admitted to the participating hospitals during the study period for the treatment of pregnancy-related complications (such as ectopic pregnancy or abortion), having delivered, or within 42 days of termination of pregnancy, and who fulfilled at least one of the conditions stated in the WHO criteria  5] were were5] wThe sample size was determined by a single population proportion formula by assuming the prevalence of maternal near-miss in Ethiopia to be 7.9% . ConsideWomen who experienced a maternal near-miss event during pregnancy, delivery or the postpartum period were identified prospectively by well-trained midwives and nurses in each hospital. Data relating to the most important variables were abstracted from the medical record of the participants using the WHO data abstraction tool, with some modifications . The datThe supervisors in all participating hospitals were responsible for checking the completeness of the information. The enumerators filled in the date and signed each questionnaire, which was later checked, edited and signed by the supervisors regularly at each hospital. The data that were collected using hard copies were kept in a locked cabinet by each supervisor until gathered by the principal investigator during supervision. Following this, the data were entered into Epi Info 7 software, and transported to SPSS version 20 and Open Epi computer software for final analysis.The total incidence of maternal near-miss in the hospitals involved in this study was calculated using the maternal near-miss incidence ratio (MNMIR) formula. This was calculated by dividing the number of maternal near-miss cases during one year by the total number of live births during the same year. The incidence ratio in each hospital was also calculated with a 95% CI. In addition, hospital access indicators, such as the number of women with a maternal near-miss condition before arrival at the hospital, were calculated. Intra-hospital care indicators, such as the number of women with near-miss who developed conditions in the hospital, were also calculated. In order to determine the underlying and contributory causes of maternal near-miss, a descriptive frequency for each cause was calculated. The total number and frequency of each cause for all hospitals involved were calculated separately. The causes were categorized into underlying and contributory as per the WHO recommendation [In order to maintain the quality of data, intensive training was given to data collectors and supervisors. All health care workers working in the maternity ward of each participating hospital were also sensitized to the issue so that they would inform the enumerators when they suspected a near-miss case. In addition, inclusion criteria for maternal near-miss were printed and posted on the wall of each ward at all participating hospitals. The data collectors made a daily visit to the Delivery Ward, Obstetrics and Gynecology Ward, ICU, and Emergency Gynecology Outpatient Department to check for potential cases. The data collectors were given training to standardize methods and ensure consistency of data collection. One hospital supervisor, who was responsible for the overall quality of the data, was appointed at each participating hospital. There was frequent supervision of the included hospitals by the principal investigator. The standardized data abstraction form developed by the WHO  was usedAcceptable ethical standards were strictly adhered to throughout the study process. The study was first approved by the Institutional Review Board of the College of Health sciences, Addis Ababa University . It was also approved by the Ethical Review Committee of each hospital. Adequate explanation about the purpose of the study and a letter of support was given to all concerned bodies. For studies that are not clinical trials that involve invasive procedures, taking verbal consent is the standard requirement of the Institutional Review Board of Addis Ababa University. Hence, verbal consent was taken to abstract pertinent information from the participant’s record. The anonymity of the participants was respected via the use of codes rather than the name of the participant. The names of the participants were not reported in the findings of the study to ensure confidentiality.During the one-year period, a total of 238 maternal near-miss cases and 29,697 live births were reported in total for all participating hospitals, which produced a total maternal near-miss incidence ratio of 8.01 per 1000 live births .The highest proportion of cases was reported from Tikur Anbessa hospital (30.7%), followed by St. Paul Millennium Medical College (23.1%), and the lowest proportion was observed at Zewditu Memorial Hospital .The majority (88.2%) of maternal near-miss cases were referred from other health facilities and an ambulance was used by most of the mothers as a means of transport to the study hospitals. A significant number (68.5%) of maternal near-misses occurred before arrival at the participating hospitals .The number of major organ dysfunctions seen in the majority of maternal near-miss cases were Coagulation/Hematological at 114 (47.9%), followed by Neurologic at 97 (40.8%), and Cardiovascular at 96 (40.3%). Hepatic dysfunction was the least-reported organ dysfunction in audited maternal near-miss cases. Around 95 (39.9%) of the cases manifested multiple organ failure .The underlying cause for the majority of maternal near-miss cases was hypertensive disorder (53%), followed by obstetric hemorrhage (38%), pregnancy with abortive outcome (4%), and pregnancy-related infections (1%) .The major contributing causes of maternal near-miss reported were anemia (40%) followed by prolonged/obstructed labor (9%). Around 37% of maternal near-miss cases did not show any form of contributing causes .During the one-year period of the study, the incidence of maternal near-miss was 8.01 per 1000 live births in all participating hospitals. Previous studies in Ethiopia have documented a prevalence rate of 101 per 1000 deliveries  and 78.9Among the five participating hospitals, a higher incidence of maternal near-miss was observed in Tikur Anbesa Hospital (15.76 per 1000 live births). Because that hospital is the major referral hospital in Ethiopia, the possibility of obtaining severely critical cases from different parts of the country and from Addis Ababa is higher.The leading underlying cause of maternal near-miss in our study was hypertensive disorder (eclampsia and pre-eclampsia), followed by obstetric hemorrhage. This finding is compatible with most studies from high and middle-income countries ,9,38,39.Pregnancy-related infection was the least mentioned cause of maternal near-miss in our study and was also reported to be the least likely cause in most of the studies completed in developed countries. The rate was also much lower as compared to some of the other African countries that had been studied –22,25. TAnemia was the major contributory cause of maternal near-miss in our study. This finding is also comparable with studies from some middle-income countries such as Iraq, India, and Pakistan –42. ThisThe majority of maternal near-miss cases have already occurred on the women’s arrival at the participating hospitals, a finding which is in line with studies from most developing countries. For example, in Bolivia, Mozambique and Somaliland, 74%, 70.7% and 74.2% of the near-miss cases, respectively, were in a critical state upon arrival at the health facilities, implying the need to focus on existing pre-hospital barriers –45. HoweThis study has many strengths. The study is the first of its kind in Ethiopia to document the incidence and causes of maternal near-miss using the newly developed WHO case identification criteria. Prospective case identification was used for a consecutive period of one year. Identifying cases prospectively over a longer period of time enabled us to avoid missing important variables, which is a drawback of most previous retrospective studies. Collecting data over a longer period of time can also help to gather a representative sample. In using the WHO criteria, we were able to determine which of the criteria were mainly applicable to the study hospitals. The use of a standardized WHO data abstraction tool to abstract data was also one of the strengths of the study, which might also have had its own implications for the quality of the study.However, our study had certain limitations. The follow-up time used by the WHO to define maternal near-miss has a duration of 42 days postpartum. However, because of logistic and feasibility concerns, our follow-up time was limited to only the length of the hospital stay. This might have caused us to underestimate the magnitude of maternal near-miss. The study also failed to abstract all maternal near-miss indicators such as the interventions provided for maternal near-miss women, which are important components of quality of care. The other limitation of the study was that our study was carried out only in public health facilities. Hence, it does not represent cases of maternal near-miss that occur in private health facilities.The study demonstrated a lower maternal near-miss incidence ratio compared to previous country-level studies. Underlying and contributory causes of maternal near-miss are still prevalent. Evidence-based interventions designed to optimize the intra-partum management of life-threatening obstetric complications, specifically hypertensive disorders and obstetric hemorrhage, could reduce the occurrence of maternal near-miss problems occurring during hospitalization. The majority of the near-miss cases happened before the women’s arrival at the participating hospitals, which underscores the importance of eliminating the pre-hospital barriers. Hence, further research is recommended to explore those barriers.S1 Table(DOCX)Click here for additional data file.


LII) model using geospatial datasets of the human footprint, as well as incorporation of other indicators of ecological integrity such as biodiversity and vegetation departure. Our LII model serves as a general indicator of ecological integrity in a regional context of human activity, biodiversity, and change in habitat composition. We also discuss the application of the LII framework in two related coarse-filter landscape conservation approaches to expand the size and connectedness of protected areas as regional mitigation for anticipated land-use changes.Land managers increasingly rely upon landscape assessments to understand the status of natural resources and identify conservation priorities. Many of these landscape planning efforts rely on geospatial models that characterize the ecological integrity of the landscape. These general models utilize measures of habitat disturbance and human activity to map indices of ecological integrity. We built upon these modeling frameworks by developing a Landscape Integrity Index ( Recently there is increasing emphasis by landscape ecologists and land managers on incorporating broad-scale ecosystem health information into management decisions that cross land ownership boundaries. Several U.S. agencies are partnering with local governments, non-profit, and other groups in using a landscape approach for identifying important areas for restoration and conservation , 2. The The landscape approach to conservation planning often involves the development and synthesis of broad-scale indicators of resource distribution, status, and condition . One treWhile approaches to evaluate and map the intensity of human activity provide general indicators of ecological integrity across landscapes to inform land management decisions, challenges with these approaches arise when considering the implications of other landscape-scale processes that may not be directly linked to human development , 22. AltLII) as a landscape indicator of ecological integrity. This modeling framework builds upon previously-published methods to map the degree of human modification in the environment . Our framework is based on landscape measures of human influence and modification, biodiversity , and other measures of landscape change . We focused on developing a computationally simple yet robust approach to model LII that incorporates several components of ecological integrity. We discuss the process by which this LII model was developed and present how land managers may apply this LII modeling framework to inform regional conservation planning on public lands in a region of southern Colorado and northern New Mexico, USA. Although we present model results for a specific region in the western USA, the framework can be replicated elsewhere where sufficient data exist.In this paper we present a framework to quantify and map a Landscape Integrity Index  and Española, NM .The study area in which we applied this landscape modeling framework was the San Luis Valley of southern Colorado and the Taos Plateau of northern New Mexico  of arid shrubland vegetation at elevations between 2,000 m and 2,400 m .This region was chosen on the basis of recent landscape planning efforts implemented by the U.S. Department of the Interior’s Bureau of Land Management (BLM) to evaluate regional compensatory mitigation opportunities for utility-scale solar energy development on public lands . ApproxiLII builds on previous approaches that focus on mapping and quantifying the degree of human modification across landscapes ),d models , 16, 17 HII model. We developed distance decay functions for all input layers that expressed the relationship between ecological impact and distance from the input feature. These distance decay curves varied based on the presumed degree of impact for each input dataset. Distance decay functions for input datasets that have higher site impacts  were parameterized with logistic functions whereas distance decay functions for input datasets that have lower site impacts  were parameterized with linear functions . Because all HII values were represented along the same continuous scale (0 to 1), we overlaid all 16 HII models and used cell statistics to compute the minimum HII value as the composite measure of HII in the final model. The final HII model was calculated within the native 90-m raster; this HII output model was later used to model LII . The normalized 240-m raster of species richness was later used to model LII  as the odel LII .LII model as an added measure of ecological function and composition. Downloaded VDEP values ranged from 0 to 100 to depict the amount current vegetation has departed from simulated historical vegetation reference conditions. We used the normalized inverse VDEP values along the same low-high gradient as the HII (ranging between 0 and 1). In this way, the scale of normalized inverse VDEP values was identical to the HII scale . The normalized 30-m raster of vegetation departure was later used to model LII . We used ArcGIS v 10.3 with the Spatial Analyst Extension to conduct the moving window analysis. The resulting map depicted landscape integrity across the study area with LII scores ranging from 0 to 1 for each 90-m pixel, based on 1 km moving widow averages surrounding each pixel. LII values closer to 0 represent low landscape integrity; values closer to 1 represent higher landscape integrity. We summarized landscape integrity across the study area and evaluated how LII scores differed by land ownership type through a one way Analysis of Variance (ANOVA).All normalized raster models of  windows . Equal wLII scores to modeled human footprint scores computed by Leu et al. [LII model incorporated additional spatial indicators of ecological integrity that were not directly related to human land use , we expected there to be differences between the models that would result in a weak or moderate correlation.We evaluated our landscape integrity model in two ways. First, at 100 randomly selected points across the study area, we compared u et al. . Becauseu et al.  focused LII values between currently protected and unprotected areas according to the Protected Areas Database [LII values at 50 randomly selected locations within protected and unprotected areas  and compared LII between these protection levels using a Welch’s two sample t-test. All statistical analyses were performed in R 3.2.3 [Second, we compared Database . We querDatabase . We then R 3.2.3 .LII to inform land management options as mitigation for anticipated solar energy development on the SEZs in the study area. The BLM implements a landscape approach in the mitigation hierarchy to avoid, minimize, and compensate for the impacts of land use decisions, including solar development [LII model may be used in BLM’s landscape approach to develop empirically-based mitigation priorities based on two ecological conservation goals: (A) maintaining ecological connectivity between protected priority areas of conservation and (B) increasing the size of the protected area network based on landscape integrity.We highlight example applications of the elopment . Among oLII model to develop coarse-filter naturalness-based connectivity models that link the ecological priority areas that are currently protected to preserve biodiversity. There is a growing interest among conservation planners in identifying conservation corridors based on broad-scale measures of ecological integrity or “naturalness” . To. ToLII m”  as the threshold in identifying high-integrity lands under this approach. We summarize the results of this analysis to identify conservation opportunities as potential mitigation for solar development on the BLM SEZs.Second, we used the HII, species richness, and vegetation departure were averaged to produce the LII . Lands managed by Federal government agencies contained average LII values of 0.574 (±0.114 SD). Private lands, on the other hand, contained average LII values of 0.472 (±0.155 SD). These LII values on private lands were significantly lower than LII values on Federal- or State-managed lands because most of privately-owned lands were utilized by humans  (There was a significant difference in culture) .LII scores and the human footprint model developed by Leu et al. [LII scores within protected areas were greater than LII scores in unprotected areas . On average, the LII value within protected areas was 0.611 (+/- 0.022 SE), whereas the LII value within unprotected areas was 0.524 (+/- 0.023 SE). Rural activities such as agriculture and livestock grazing were the primary human land use drivers of ecological integrity across the study area. Because these activities may have historically occurred in both protected and unprotected areas , the ecological effects of these activities may still be measurable on the landscape through datasets such as vegetation departure ..Fig 6). LII model could be used to expand the protected areas network by identifying high integrity lands adjacent to current ecological priority areas that could be afforded protection. Using the upper 30% of LII values, we were able to identify over 900 km2 of high integrity adjacent land that could be considered to expand the protected areas network  and vegetation departure, which could be used as a measure of ecological departure from the historic conditions based on human activity or other environmental drivers such as climate change, invasive species, or wildfire [LII values were greater within areas already protected for biodiversity, where human disturbance has been minimized and habitats have been managed to maintain natural processes. On average, LII values within protected areas were about 16.6% greater than LII values outside protected areas. We also noted a moderate correlation between our LII values and modeled estimates of the human footprint by Leu et al. [HII model is another representation of the human footprint that is highly correlated with the footprint model by Leu et al. [LII model to retain some correlation with the human footprint.Efforts to quantify and map human developments have provided reasonable coarse-filter indicators of ecological integrity by mapping the degree of “naturalness” across landscapes e.g., , 17. Howwildfire , 43. As u et al. . This fiu et al.  . This functionality would help land managers and conservation planners better understand status and trends in landscape integrity.Between these two approaches, we identified over 1,000 km network . Coarse- network , 45. LikLII model framework may assist other landscape-scale structured multi-criterion support frameworks by providing input on ecological values and status/trends.Our study highlights an ecologically-driven framework to conservation planning. However, landscape approaches to conservation planning often require the need to balance tradeoffs among different and often conflicting land uses  , 47. OurS1 Table(DOCX)Click here for additional data file.


Dictyostelium discoideum has become an important model organism to study the cell biology of professional phagocytes. This amoeba not only shares many molecular features with mammalian macrophages, but most of its fundamental signal transduction pathways are conserved in humans. The broad range of existing genetic and biochemical tools, together with its suitability for cell culture and live microscopy, make D. discoideum an ideal and versatile laboratory organism. In this review, we focus on the use of D. discoideum as a phagocyte model for the study of mycobacterial infections, in particular Mycobacterium marinum. We look in detail at the intracellular cycle of M. marinum, from its uptake by D. discoideum to its active or passive egress into the extracellular medium. In addition, we describe the molecular mechanisms that both the mycobacterial invader and the amoeboid host have developed to fight against each other, and compare and contrast with those developed by mammalian phagocytes. Finally, we introduce the methods and specific tools that have been used so far to monitor the D. discoideum—M. marinum interaction.In recent years,  Dictyostelium discoideum is a soil amoeba that feeds on bacteria by phagocytosis. The Amoebozoa branch split from the common lineage leading to fungi and animals, shortly after these crown organisms split from the Plant lineage  haploid genome, organized into 6 chromosomes, which has been sequenced and annotated , a major catabolic pathway in eukaryotes  in mammals] and Atg8a  , share many molecular and biological characteristics with galectins. Dsc are highly expressed upon starvation  but not the less virulent L. hackelieae, suggesting a role in innate immunity , causing leprosy and tuberculosis, respectively. The latter represents the most severe bacterial diseases, responsible for 1.8 million deaths worldwide in 2015 . One of the important features of Mtb is its capacity to persist inside its host in a non-replicating state with low metabolic activity. This phenomenon is called dormancy (or latency) and affects 2–3 billion people . Latent tuberculosis is non-transmissible and presents no clinical manifestation. However, the disease reactivates in 5–10% of the cases usually as a consequence of immunosuppression, becoming contagious. Therefore, providing treatments to prevent the reactivation of latent tuberculosis is an important concern in the control of this disease  and M. marinum  or Mycobacteria Other Than Tubercle bacilli (MOTT), which includes among others the species M. marinum strain M was sequenced and annotated in 2008 by Stinear et al.   called ESX1-5 , used for vaccines, lack a partially overlapping region of the ESX-1 locus, which was called Region of Difference 1 (RD1). This region comprises two genes that encode the above mentioned secreted peptides ESAT6 and CFP10. Early studies using transposon libraries and purified proteins identified ESX-1, and in particular ESAT6 and CFP10, as membranolytic factors in both Mtb and M. marinum . After an initial incubation without antibiotics, to allow the phagocytosis of M. marinum, streptomycin was added to the infection sample to impede the growth of extracellular bacteria. In this first approach, the increased growth of M. marinum was assessed by direct observation, but other quantitative methods such as luminescence recording, fluorescence-activated cell sorting (FACS) and colony-forming units (CFUs) counting have confirmed the intracellular proliferation of this bacterium within D. discoideum, both in static and shaking cultures  and performing immunofluorescence assays  an initial phase during the first 12 h post-infection (hpi), when M. marinum actively manipulates the D. discoideum phagocytic pathway to convert the phagosome where it resides into a replication-permissive niche [mycobacteria-containing vacuole (MCV)], (ii) an enhanced proliferation phase between 12 and 37 hpi, and (iii) a phase of arrested proliferation and/or decreased bacterial load due to bacterial death or release after 37 hpi  is almost undetectable on the MCV at the end of this infection phase  harbor actin-negative MCVs which accumulate VatA and VatM (a transmembrane subunit of the vATPase), while losing the endocytic marker p80. Interestingly, p80 is not lost from the phagosome containing M. smegmatis and the avirulent mutant M. marinum L1D , is also essential for the establishment of the MCV, assisting M. marinum in the retrieval of the vATPase from its niche. On the contrary, the small GTPase RacH of D. discoideum contributes to the maturation of the MCV into phagolysosomes, reducing the intracellular bacterial load   . Exclusion of DAPI (a membrane-impermeant DNA binding dye) from the nuclei of live amoebae during ejection demonstrates that M. marnium does not kill or induce leakage of its host while egressing by this mean  was infected with red fluorescent M. marinum, and a wt acceptor strain expressing GFP was added to the infection after 12 h. Transmission from racH- infected cells to wt cells was reduced over eight-fold  in an otherwise intact RD1 locus are defective in hemolysis, cytolysis, and cytotoxicity  enhanced formation of autophagosomes, and (iii) recruitment of the xenophagy machinery  to the damaged MCV. These responses to MCV damage are significantly reduced or even abolished when M. marinum lacks the RD1 locus and, more specifically, ESAT-6 and CFP-10   and Figure Salmonella-containing compartment (SCV) has already been described, although the mechanism is different. Salmonella subverts the Rab9-dependent retrograde trafficking of mannose-6-phosphate receptors in human cells, which results in fusion of the SCV with lysosomes that are reduced in hydrolytic enzymes  and two TORC1 activators, the Rheb GTPase and Lamtor1 [a member of the guanine nucleotide exchange factor (GEF) Ragulator complex] localize to damaged MCVs coinciding with reactivation of TORC1 at 7 hpi  by the fusion of autophagosomes with the MCV (see section M. marinum Exploits D. discoideum Lipids).The membrane damage inflicted by M. marinum bacilli are able to break completely their MCV and finally access the D. discoideum cytosol  is required for the recruitment of Atg8 to the distal pole of ejecting M. marinum . In these cells both bacteria form ejectosomes and recruit Atg8 to their distal pole  harbored in the Mtb genome and required for lipid and fatty acid (FA) metabolism , which is also reflected by a higher number of genes involved in lipid metabolism , a fluorescent phospholipid precursor, it was observed by live microscopy that host phospholipids accumulate at the membranes of the MCV, most likely by standard membrane trafficking , LD-like structures disappear, but neutral lipids and sterols, which can be detected by Bodipy 493/503 and filipin staining, are homogenously distributed within the MCV Figure . Interesg Figure .D. discoideum cells are treated with exogenous FAs  polysaccharides, which are in turn covalently attached to a peptidoglycan backbone  from FAs released from D. discoideum LDs and phospholipids  mutant, bacteria growth is inhibited starting from 20 hpi, the time at which M. marinum reaches the cytosol , LD proteins such as the m Figure . Perilipm Figure . ImportaM. marinum by coalescence with LDs and lateral diffusion  contribute to M. marinum virulence in D. discoideum and limit bacterial entry in human macrophages  technologies, numerous methods to investigate the host-pathogen interaction at different levels  have been developed. Among them, RNA sequencing (RNA-Seq) is becoming the standard to analyze the transcripts of each actor involved in a bacterial infection, either independently (bacteria or host) or simultaneously (bacteria and host) by dual RNA-Seq  and between the two amoebae D. discoidum and A. castellani, while an intermediate behavior was observed in cells derived from fish (carp CLC leukocytes), probably due to their higher similarity with natural M. marinum hosts. Thus, the authors concluded that M. marinum has both conserved and host-specific virulence determinants. Regarding the conserved virulence factors, transposon interruption of PDIMs, ESX-1, or Mce1/4 leads to high attenuation of M. marinum virulence in multiple hosts. In addition, a new virulence factor of M. marinum was highlighted and validated in vivo, the cpsA gene. This gene encodes a protein of the LytR family of transcriptional regulators and has been recently demonstrated to be required for M. marinum cell wall integrity and virulence in the zebrafish model , which allows the analysis of fitness and genetic interactions in microorganisms by using random transposon insertion libraries in bacteria . The REMI method was first described in Saccharomyces  has recently been developed for M. marinum within the amoeba D. discoideum. The comparison with studies carried out in human cells with Mtb revealed that the infection cycles of both bacteria share numerous similarities. However, many of the virulence mechanisms used by both pathogens to subvert the immune response of their hosts remain to be elucidated. We propose the D. discoideum—M. marinum system as a suitable and powerful model to study infection by tuberculous mycobacteria.In this review, we have described the so far known processes involved in the intracellular cycle of It needs to be noticed that not all the markers listed here were monitored in all the listed strains, and vice versa. Please see main text and supplementary tables for more details. IFA, immunofluorescence assay; TEM, transmission electron microscopy; qPCR, quantitative polymerase chain reaction; SEM, scanning electron microscopy; CLEM, correlative light and electron microscopy.EC-M, CB, LL, and AL-J wrote the original draft. EC-M and CB drew the figures and prepared the tables. EC-M, CB, LL, and TS reviewed and edited the draft. TS supervised this work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Drinking is viewed by young people as a predominantly social activity which provides an opportunity for entertainment and bonding with friends. Using Bourdieu's concepts of habitus, field and capital, this article explores young people's attitudes and beliefs around alcohol use, influences on behaviour, and the role of peers, with a view to informing the development of preventive interventions. Semi‐structured interviews were conducted with 28 young people aged 18–20 in the south west of England. We describe how friends were integral in drinking experiences, and drinking with friends was equated with fun and enjoyment. In this way, the desire for social and symbolic capital appeared to be a key motivator for adolescent drinking. Critically, however, wider cultural norms played the predominant role in shaping behaviour, via the internalisation of widely accepted practice and the subsequent externalisation of norms through the habitus. Applying Bourdieu's theory suggests that population‐level interventions that regulate alcohol consumption, and thus disrupt the field, are likely to facilitate behaviour change among young people by driving a response in habitus. Alcohol consumption rates among young adults in the UK are some of the highest in Europe ; structuring in that it helps to shape behaviour; and a structure in itself, because it is comprised of a system of dispositions which generate tastes and inclinations Grenfell . Habitusillusio); they believe in the game and its stakes (doxa); and through their involvement they agree that the game is worth playing (collusion). In other words, all of the actors have awareness of, and adhere to, the ‘rules of the game’ and they embody a ‘feel for the game’ such that they sense the ‘imminent future’ and ‘sense of direction’ of the game , economic , and/or social capital  as well as symbolic capital, which takes on this status once it becomes legitimate or recognised by others ] + field = practice, essentially stating that practice is shaped by the relationship between an individuals’ habitus and their position in a field within the state of play of that field Grenfell . Thus beet al. This study was a nested qualitative study selecting participants from the Avon Longitudinal Study of Parents and Children (ALSPAC). ALSPAC is a population based cohort study of children born to mothers resident in Avon in the South West of England who had expected dates of delivery between 1st April 1991 and 31st December 1992  which were facilitated by a topic guide, and which explored participants’ views and experiences of alcohol, tobacco and cannabis use. One interview was conducted with a young person and their friend whilst the remainder were conducted on a one‐to‐one basis. Interviews were conducted in participants’ homes, universities or local cafés, and focussed on young people's: initiation into and ongoing use of substances; reasons for use; experiences of drug and alcohol education; understandings of the associated harms, risks and perceptions of risk; outlook on the social context and social networks in which use occurred; and the role of peers, subjective norms, attitudes, beliefs and intentions in shaping substance use. Interviews were digitally‐recorded and transcribed verbatim. Participants provided signed informed consent and received a £10 voucher for taking part. All interview data were fully anonymised, with participant names being changed to preserve anonymity.Data analysis was ongoing and iterative, such that early data analyses, and the identification of emergent themes, informed the development of topic guides for subsequent interviews. Transcripts of interviews were imported into NVivo version 10  and analysis was completed using this software. Transcripts were read and re‐read and coded inductively, initially employing open coding to categorise and organise the data. A constant comparative approach was used to identify similarities and differences between accounts, to explore relationships, and to continually refine codes and develop categories and sub‐categories until data saturation was reached with no new data emerging in the final interviews. Notes and memos were written throughout the period of analysis to facilitate this process. Two researchers coded the data independently  (owing to staff changes and a need for GJM to become immersed in the data) thus the key categories and themes were corroborated. The major themes identified in relation to the role of peers in young people's alcohol use were: the social context to drinking; peer influence, pressure or selection; safety, trust and responsibility; and judgement and discourse around others. Notably, however, we found that underpinning the study themes was evidence of a deeply entrenched culture around pre‐drinking and drinking. In this way, analysis of the impact of peers could not be considered in isolation and the wider environment and socio‐cultural context needed to be taken into account to more fully understand young people's behaviour. Bourdieu's concepts habitus, field and capital helped to explain the findings by capturing the importance of the cultural context, and by implicitly accounting for the role of previous and ongoing experiences and circumstances throughout adolescence, and the social nature of alcohol consumption. Bourdieu's concepts of the doxa and collusion also capture the importance that young people ascribed to the protection from risk provided by the social group and the need to be responsible or look out for each other – mediated via a mutual understanding and an awareness of the ‘rules of the game’. We note that the links between the data and the theory of Bourdieu were made following data analysis to help explain the findings and to identify possible strategies and/or interventions that could be implemented to reduce the harms associated with adolescent alcohol use.I can't think of a thing that you go out to in the evening except bowling and things like that, where you don't drink, and even bowling you probably do as well, umm yeah, you just kind of do in the evenings, it's what occurs. I1Why do you think that most people drink? What do you think is the biggest reason for young people?RI think it is just a chain reaction. Everyone else is drinking; I'll have a drink as well. I think that's it basically. Wider British cultural norms around alcohol were characterised by a tolerance and acceptance from parents around young people's drinking, the ubiquity of alcohol through society, and the integral nature of drinking in the social world. Among young adults in this study, the internalisation of cultural norms and the expected and accepted practice of drinking into the habitus played a critical role in shaping and patterning young people's drinking behaviour and their engagement with the field (here representing the night‐time economy (NTE), in which actors could be considered to be young people, the alcohol industry, and alcohol‐related businesses such as bars and clubs). Owing to this internalisation of a broadly accepting attitude towards drinking, the habitus of young adults became a structure which generated dispositions and inclinations that tended towards an expectation of drinking and a normalisation of the behaviour. Habitus placed drinking as accepted and central to the social world, such that drinking was something which ‘unthinkingly’ occurred. Participants’ reflected an instinctive understanding of the social context and their ‘feel for the game’:RIt's more habit as well because everyone does it and I always do it. You don't even really question why you do it sometimes. It's just something that everyone does.IIt's just normal?RYeah it's just normal isn't it? You just on a weekend think oh I will go out tonight, and then you go to a bar because it is such a social area where all your friends go and just drink because you are at a bar. Habitus was attuned to the doxa of the night‐time economy and through the habitus, actions were broadly attuned to each other in line with experiences, precedents and circumstances. As Bourdieu and Wacquant : 127 higIFirstly, if you can tell me about a typical Friday night out, Saturday night out for you? …RUmm, they kind of vary don't they? We normally either go round a friend's house to get dressed or get changed and so have a couple of drinks at their house, get a taxi into town about eleven, start off in the quieter pubs, work up to three pubs, and then normally get home about 4 o'clock, rather drunk normally which is quite fun. ISo when you get into town what will you be drinking and where will you go?RWe always start in this one bar because drinks are one fifty, so it's cheap to drink. Usually WKD's and bottles of beer and stuff like that. Then we'll leave there and either go all over, can't really say a specific place because we go everywhere but then I'll drink vodka redbulls all night because they are cheap and just shots of Sambuca and tequila and stuff like that. Anything that's cheap really, in different places the prices vary. With habitus and field interacting in this way, alcohol was clearly pervasive in young people's lives and the habitus of young adults was one where drinking in town centres at weekends was a regular, somewhat patterned activity and a ‘norm’. Drinking was seen as fun rather than problematic or risky in any way. There was little mention of moderate drinking in local pubs, rather, alcohol was widely available and cheap and the culture of drinking revolved around pre‐drinking (‘pre‐loading’ or drinking before going out) and then heavier drinking in bars and clubs in town centres.That was the philosophy. Just go out and get smashed and have a good time. .I've learnt that if you spend twenty quid on a night out and don't remember much of it it's not actually worth it in the end so I'd rather spend ten and having at least one that you kind of remember and enjoyed it's more worthwhile However, although drunkenness was a norm for most young adults, the habitus involved strategies for controlling intake and behaviour, reflecting the assimilation and impact of prior histories and experiences and the influence of cost:IOk if we think a little bit about drug and alcohol education, can you remember if you had any of it?RNot really. I'm not sure I really had it. my parents] are perfectly happy to buy me booze, they just prefer if I keep it in moderation but they understand university, the whole scene. They understand that things are going to happen. They , that's when you, did you decide that you were going to start drinking more or was it just something that happened?So when you got there ?And when you went out would you be like that with them [RUmm I think I didn't drink as much as them but I did drink enough to feel pretty drunk and I didn't really like it because I didn't feel safe when everyone's running away from you and you don't know how you're going to get home.IOk how else did it make you feel?RUmm I don't know, a bit like gross umm, not very well behaved, for women to act like that I think it's a bit gross. Young people were clear when friends or others displayed behaviours distinct from their own. First, participants described instances where friends could ruin a night out or make individuals feel vulnerable:I just hate seeing, like walking down the street and seeing like girls that are so drunk with like a dress up; like that look to me is like they do that and they think that they're gonna impress boys. And I'm like hmm, if I ever got like that shoot me, I can't bear to be like that. However, these were generally seen as unfortunate but acceptable consequences of drinking. Second, many displayed a disapproval and distancing from those who were considered to drink to excess and display distasteful and/or antisocial behaviours:doxa. In line with similar practices and dispositions being produced by the habitus among individuals that occupy close positions in a field RThere are a couple of friends that are always the drunkest, well not the drunkest but always going to be one of the drunk ones. But they are not drunk, drunk, drunk, drunk, like vomit everywhere. They may be passed out in the cab but they are not, I don't have any friends that are those people. Such individuals behaved in a way that neither matched the field of participants nor was aligned with the Bourdieu , particiIn this study, we have applied Bourdieu's concepts of habitus, field and capital to show how the alcohol drinking culture of the UK plays a major role in shaping alcohol use behaviour among young people. Using Bourdieu's equation:  + field = practice, we have described how the internalisation of peer and cultural behavioural norms (‘practice’), alongside historical precedent, accepting family contexts and an absence of information and education, generates a shared habitus among young people that constructs heavy alcohol use as normative and is at home in the night‐time economy (‘field’). The continual interaction between the habitus and this field generates and sustains such practice.et al. et al. We have also reported how the habitus of young people changes from early adolescence to young adulthood, from one of experimentation, excitement, intoxication and social conformity to one that structures pre‐drinking, drinking and engaging with the NTE as a norm but which involves greater choice and control around intake and behaviour. In addition to the above factors which shape habitus, negative experiences of drinking and the changing nature of peer influence shaped views and practices over the course of adolescence, contributing to the shift in this habitus between adolescence and young adulthood. Our finding supports previous studies, which have highlighted a shift in drinking behaviour during teenage years, from an initial focus on intoxication, to a more experienced and refined drinking culture where young people avoid getting too drunk or losing control, and where drinking customs evolve within friendship groups . Our findings support those of others, which have similarly highlighted the inextricable link between socialising and alcohol use, and the association between alcohol and lowered inhibitions, social bonding, fun and enjoyment (Coleman and Cater et al. In line with the social nature of drinking, young adults highlighted the importance of feeling trust and safety among friends in the peer group, and acknowledged a shared set of tacitly accepted rules, in Bourdieu's terms ‘an agreement in ways of judging and acting’ underpinning a ‘mutual understanding’ Bourdieu : 145. Thet al. et al. While our findings concur with accounts in qualitative studies, they contrast in some ways with data reported in quantitative studies. The latter have demonstrated that peers play a prominent role in driving alcohol use among adolescents and that the impacts of peers may be mediated by peer selection and/or peer influence. Whilst we found evidence for peer influence, this was in a broader context of the impact of the wider alcohol drinking culture which set alcohol consumption in the centre of adolescents’ social lives. Moreover, we did not find substantial evidence to support peer selection or peer pressure as having a prominent impact on past or current alcohol use, with just a minority of participants mentioning the likelihood of losing contact with friends owing to different patterns of drinking. Friendship groups were mixed and those who drank more moderately were not socially excluded, as has been demonstrated in other studies (Frederiksen et al. et al. et al. et al. et al. Applying Bourdieu's concepts of habitus, field and capital to our data provides a means of considering possible interventions that may help to prevent short and long‐term harms associated with heavy alcohol use in adolescence and young adulthood. First, as outlined above, Bourdieu highlights how habitus and field continually interact, and how habitus is continually influenced by practice, while habitus simultaneously helps to shape practice and the social world. Bourdieu also uses the term ‘hysteresis’ to describe the result of a disruption in the relationship between habitus and field and a change to the relative value of capital Hardy . He statA major focus of public health policy and practice should therefore be in generating momentum and evidence to contribute to the implementation and evaluation of interventions at the population level. Nevertheless, it is important to note that the lack of information about risk communicated to young people, combined with the importance of family and school‐based experiences in shaping habitus, and the heavy drinking culture of university, also suggests that ongoing adjustment to the habitus of young people will require intervention targeted to the individual, family, school, and university contexts. While young people were aware of the need for trust, safety and responsibility, the longer‐term risks to health associated with alcohol use were not considered relevant and it is likely that these need to be made much more pertinent to young people in order to change behaviour.In this study, we have highlighted that adolescent drinking is primarily viewed as a social activity and that friends are integral in drinking experiences. Critically, we found that cultural and peer norms played a prominent role in shaping and normalising alcohol use behaviour. Application of sociological theory to the data suggest that a population‐level approach, comprising alcohol‐control policies that regulate the environment in which alcohol is marketed and consumed should be a primary goal of policymakers and practitioners in order to change behaviour and reduce alcohol‐related harm.Supplementary Table 1. Alcohol use and drinking pattern of participants.Click here for additional data file.


Video vignettes are used to test the effects of physicians’ communication on patient outcomes. Methodological choices in video-vignette development may have far-stretching consequences for participants’ engagement with the video, and thus the ecological validity of this design. To supplement the scant evidence in this field, this study tested how variations in video-vignette introduction format and camera focus influence participants’ engagement with a video vignette showing a bad news consultation.. One hundred eighty-one students were randomly assigned to watch one of the six resulting video-vignette conditions as so-called analogue patients, i.e., they were instructed to imagine themselves being in the video patient’s situation. Four dimensions of self-reported engagement were assessed retrospectively. Emotional engagement was additionally measured by recording participants’ electrodermal and cardiovascular activity continuously while watching. Analyses of variance were used to test the effects of introduction format, camera focus and their interaction.Introduction format  and camera focus  were varied in a randomized 2 × 3 between-subjects designp = 0.048, p = 0.051, p = 0.003, emotional engagement (p = 0.045, The audiovisual introduction induced a stronger blood pressure response during watching the introduction (emotional engagement in analogue patients. This evidence can inform methodological decisions during the development of video vignettes, and thereby enhance the ecological validity of future video-vignettes studies.Our findings imply that using an audiovisual introduction combined with alternating camera focus depicting patient’s emotions results in the highest levels of  High-quality communication is an essential requirement for physicians when conducting medical consultations. It enables physicians, for example, to adequately provide information to, and gather information from, patients . The groA video-vignettes design requires the development of multiple (brief) videos of a scripted medical consultation . The keyPrevious research has indicated that analogue patients can be validly used as proxies to actual patients to evaluate physicians’ communication behavior , 4. HoweTwo of the most salient methodological issues with regard to the video-vignettes design are how the video vignettes are introduced and which focus is used to show the medical consultation. Because these two issues may crucially influence analogue patients’ engagement when viewing video vignettes, they are the focus of the current study. An introduction to the video vignette can be added to familiarize analogue patients to the setting and the characters, inform analogue patients about the video patient’s situation, instruct, and/or engage analogue patients. Various introduction formats may be used. For example, the researcher could show a written introduction on paper or a (computer) screen or provide an audiovisual introduction, i.e., showing video images with a neutral voice-over or a videotaped scene in which the patient introduces his−/herself . LikewisAlthough no evidence exists regarding the effects of introduction format or camera focus on video-vignette engagement, some hypotheses can be put forward based on literature from other fields. With regard to introduction format, engagement might be highest when stimulating multiple sensory modalities . An audiThe aim of this study was to systematically investigate the effects of introduction format and camera focus on analogue patients’ video engagement. Firstly, analogue patients’ engagement was expected to be the strongest when watching a video vignette with an audiovisual introduction, when compared to a written introduction. Secondly, alternating the camera focus between the physician and the video patient was expected to cause a higher level of engagement, as compared to a physician-only variant. More specifically, alternating the camera focus depicting the video patient’s emotional expressions, was expected to cause higher levels of engagement than an alternating variant that focusses on the patient at relatively neutral moments, and a physician-only variant. Thirdly, combining an audiovisual introduction and alternating camera focus depicting the patient’s emotional expressions, was expected to induce the highest levels of engagement.emotional engagement during watching the introduction and the medical consultation part of the video vignette [This experimental video-vignettes study used a videotaped scripted medical consultation in which two methodological elements (introduction format and camera focus) were varied in a randomized 2 by 3 between-subjects design, resulting in six video-vignette conditions see Fig. . Video evignette , 12. TheCancer-naive individuals aged between 18 and 40 were recruited as analogue patients through a Psychology and a Communication Science research eduation program of the University of Amsterdam. Participants were eligible if they: 1) were not using medication related to cardiovascular disease or hypertension ; 2) were literate in Dutch; 3) had no prior experience with oncological consultations as a patient or a patient’s relative.The scripted video vignettes were previously developed as part of a research line addressing understanding and improving physician-patient information transfer within the field of oncology. The video vignettes showed a bad news consultation involving an oncological surgeon (referred to as ‘the physician’ in this manuscript) and a patient discussing the patient’s cancer diagnosis, prognosis, treatment options and side-effects. Two identical versions were created for each video-vignette condition, one with a male and one with a female actor in the role of the video patient. By matching analogue patients’ gender to that of the video patient, identification was optimized. A detailed description of the developmental process of the video vignettes used in the current study can be found in a previous publication (see ).A) an audiovisual introduction, depicting a video fragment of the patient in the waiting area of a hospital while a neutral voice-over reads the introductory text out loud; B) a written introduction, in which the same introductory text appears on the screen in five successive parts (each showing approximately 9 s) in white letters on a grey background. The duration of both introduction formats was 49 s.An introduction preceded the video vignette to present the video patient and his/her medical situation. Two formats were developed see Fig. : A) an a1) physician-only: focusing on the physician during the entire medical consultation; 2) neutral alternating: alternating camera focus between the physician and the patient, focusing on the patient at relatively neutral moments in the consultation; 3) emotion-focused alternating: alternating camera focus between the physician and the patient, focusing on the patient at emotional moments in the consultation. For variant 1 only (medium) close-up shots of the physician were used. Variant 2 and 3 were created by combining multiple camera shot types, i.e., by means of (medium) close-up and over-the-shoulder shots, facing the physician or the patient. The video-vignette variants varied slightly in length, between 368 and 386 s, because of small editing differences across variants, and small differences in speaking rate between the male and female video-patient versions.The medical consultation depicted in the video vignette was videotaped using multiple cameras. From these recordings, three camera focus variants were developed during editing see Fig. : 1) physA detailed description of experimental procedures and measures was previously published as part of a separate study on the relationship between  patients’ emotional stress response and memory of medical information . Here, wUpon arrival in a standardized laboratory room, analogue patients completed a digital questionnaire (T0) reporting their age, gender, weight and height , which is known to correlate with physiological activity ). They wSelf-reported engagement with the video vignette was assessed using the 15-item Video Engagement Scale (VES) [Since physiological activity varies as a function of psychological change, psychophysiological measurement can be used to make inferences about psychological processes, in particular analogue patients’ emotional arousal as evoked by watching the video vignette . MultiplPerceived realism of the video vignette, i.e., the extent to which the video-vignettes’ characters and situations are judged to be similar to real life, was assessed for exploratory purposes. This construct is thought to be related to engagement , 17 and ) is reported as a measure of effect size. It describes the proportion of variance in the dependent variable attributable to a particular independent variable (and not explained by other independent variables) [10 or square root transformations were applied on psychophysiological data. No outliers were removed.All analyses were performed using IBM SPSS Statistics 23. The 0.05 probability level was used as a criterion of statistical significance. Partial eta-squared (riables) . Suggestriables) . Self-reN = 127 to N = 180) was calculated using G-power 3.1.9.2, demonstrating 80% power to detect medium effects . The multivariate analyses were followed up by univariate analyses of variance to be able to examine the effects on the separate outcome measures. With regard to the psychophysiological parameters, follow up univariate results were only reported if significant effects were shown in multivariate analyses, to prevent type I error resulting from multiple testing.In previous research, associations have been shown between analogue patients’ gender, age, BMI and outcomes , 20, 21.N = 181) were on average 23 years old , 70% were female (N = 126), and mean BMI was 22 (SD = 2.5). Randomization was successful as no differences between the six video-vignette conditions were found with regard to analogue patients’ gender (p = 0.541), age (p = 0.084), or BMI (p = 0.515). The following associations were shown between analogue patients’ characteristics and outcomes: 1) age was positively correlated with self-reported attentional engagement (ATT-dimension) during watching the vignette , and with blood pressure (systolic and diastolic) during all time periods ; 2) men showed higher levels of diastolic blood pressure during all time periods ; 3) BMI was positively correlated with skin conductance responses (SCRs) during the consultation part of the vignette . Based on these results, subsequent analyses were adjusted for age and gender when relevant. Electrodermal activity analyses were not adjusted for BMI, as BMI was only associated with SCRs during the consultation.Analogue patients  = 1.07, p = 0.375, F = 0.80, p = 0.605, F = 1.56, p = 0.137, p = 0.045, p = 0.004).Table entclass1pt{minimaMeans and standard deviations of analogue patients’ psychophysiological activity, including the observed response during the video-vignette introduction compared to baseline activity, are shown in Table cardiovascular parameters, a medium multivariate effect of introduction format was present; watching the audiovisual introduction (format A) evoked a stronger increase in cardiovascular activity in analogue patients  = 2.70, p = 0.048, p = 0.008, p = 0.042, p = 0.896, electrodermal parameters, no multivariate effect of introduction format was shown  = 0.53, p = 0.588, With regard to the cardiovascular results showed a medium effect of introduction format  = 2.65, p = 0.051, p = 0.015, p = 0.015, p = 0.314, p = 0.187) nor an interaction effect between introduction format and camera focus (p = 0.180) were found on the cardiovascular response as evoked by the video-vignette consultation.Multivariate ion Fig.  revealedelectrodermal activity levels during the consultation part of the vignette to their baseline activity levels  = 4.08, p = 0.003, p = 0.005, p = 0.001, p = 0.142) nor an interaction effect between introduction format and camera focus (p = 0.260) were found on the electrodermal response as evoked by the video-vignette consultation.A multivariate medium effect of camera focus was found when comparing analogue patients’ = 0.88, F, 240 = 4F = 3.15, p = 0.005, p = 0.003, p-values > 0.725). Post-hoc tests revealed that analogue patients in the video-vignette conditions with the emotion-focused alternating camera focus (variant 3), perceived the video patient’s appearance and behavior as more realistic than those who watched the physician-only (p = 0.003) or the neutral alternating (p = 0.003) camera focus variants. No main effect of introduction format (p = 0.592) nor an interaction effect between introduction format and camera focus (p = 0.437) were found.Additionally, the influence of introduction format and camera focus on perceived realism of the video vignette was explored. Analogue patients scored on average 5 or more (possible range 1–7) on all three perceived realism scales Table . A mediuemotional engagement in response to an audiovisual introduction, showing the patient in the hospital’s waiting area while the story was introduced by a voice-over, as compared to a written introduction displayed on a computer screen. In particular, the audiovisual introduction caused a stronger cardiovascular response in analogue patients while viewing the video-vignette introduction. This effect was sustained during the subsequent watching of the medical consultation. Second, alternating camera focus between the physician and the patient, specifically depicting the patient’s emotions, caused the strongest emotional engagement in analogue patients, as reflected by their electrodermal response to the vignette. Alternating camera focus between the physician and the patient, depicting the patient at relatively neutral moments in the consultation, did not enhance engagement compared to showing only the physician, indicating that the effect on emotional engagement was indeed a result of showing the patient’s emotional facial expressions. Third, no effects were found on analogue patients’ self-reported engagement, with only one exception; an interaction effect of introduction format and camera focus was found on analogue patients’ self-reported emotional engagement. Focusing only on the physician during the consultation resulted in lower levels of emotional engagement when combined with the audiovisual introduction, as compared to the written introduction. This may indicate that analogue patients’ emotional engagement is disrupted by not showing the video patient during the video-vignette consultation if the video patient has been audio-visually introduced first. Fourth, exploratory analyses showed that the perceived realism of the video patient was influenced by the variation in camera focus. Findings suggest that analogue patients need to see, and not only hear, the patient during the video-vignette consultation, in particular at emotional moments, to perceive the patient and his/her behavior as realistic. Summarizing, our findings imply that an audiovisual video-vignette introduction combined with a camera focus on patient’s emotional expressions during the video-vignette consultation results in the highest levels of emotional engagement in analogue patients. The magnitude of effects found on analogue patients’ emotional engagement, in particular on the psychophysiological measures (which were medium effects), were comparable to the effects of analogue patients’ age [Video-vignette studies are imperative for the systematic investigation of physician-patient communication. Results of this experimental study indicate that methodological choices with regard to video-vignette development can influence the ecological validity of video vignettes. First, how the video vignettes are introduced mattered: analogue patients showed stronger nts’ age , and phynts’ age  or affecnts’ age  communicThe current findings correspond with previous research showing an increase in electrodermal activity and blood pressure in response to video clips in which the characters express emotions, such as sadness and fearfulness . This inalways be the best option. Researchers who do not want to show the patient at all during the video-vignette consultation should consider using a written introduction instead of an audiovisual introduction. Alternating camera focus between physician and patient showing the patient at relatively neutral moments during the medical interaction might be a suitable alternative as well.Patient emotions are an inherent part of most medical consultations and therefore inducing emotional engagement, including emotions, in analogue patients is desirable. Based on the current findings, we would thus advise to enhance analogue patients’ emotional engagement by introducing the video vignette audio-visually and by alternating camera focus, depicting the video patient’s emotions. Nevertheless, this rationale requires some qualification. First, inducing particularly strong emotions may be less desirable for research in which emotions might distract analogue patients from the task at hand, e.g., the evaluation of the physicians’ information provision . The curA strength of the current study is its combined use of a multidimensional self-reported measure of engagement and physiological measures indicating emotional engagement. Previous research using video vignettes has shown limited overlap between these measures , which uIn sum, researchers in medical communication should carefully consider how they introduce their video vignettes and which camera focus they choose, as these decisions may influence analogue patients’ engagement with the video vignette and perceived realism of the video patient. Using an audiovisual introduction and alternating camera shots focused on the video patient’s emotional expressions during the medical consultation maximizes emotional engagement, and could therefore increase the ecological validity of the video-vignettes design. This study thereby contributes to the evidence base for making methodological choices in the development of experimental, video-based research on medical communication. This will yield more robust findings on the impact of physician-patient communication on patient outcomes that can be employed to improve medical care.