Although health care settings offer an ideal opportunity for identifying people who are currently experiencing or are at risk for problems with alcohol, clinicians screen fewer than one-half of their patients for alcohol use disorders. The rate of alcohol screening may be increased, however, by applying strategies shown to promote the use of screening procedures for other medical problems, such as cancer. These strategies include group education , training given by respected colleagues , performance feedback, educational outreach visits to individual physicians , and financial incentives or penalties. Using clinic-based system protocols  can help make the implementation of alcohol screening in clinical practice both efficient and effective. Although incorporating alcohol screening into other high-priority clinical activities and screening programs remains a challenge, routine alcohol screening as a standard of care for all patients is receiving increased acceptance. Both the U.S. Department of Agriculture and the Department of Health and Human Services recommend limiting alcohol consumption to no more than two standard drinksBecause patients consider their doctors to be trusted and credible sources of health information, health care settings are ideal for implementing alcohol-screening procedures. Several screening tests to identify alcohol use disorders in patients have been developed for use in clinical settings. These tests are highly sensitive, specific, and similar in accuracy to a blood pressure measurement to detect high blood pressure or a glucose tolerance test to screen for diabetes. For patients who screen positive for alcohol use disorders, physicians can take action to promote healthy, successful outcomes. For example, both alcohol consumption and health care utilization decrease when clinicians incorporate simple procedures  into routine office visits with patients who are nondependent drinkers and provide specialized treatment for patients who are alcohol dependent a.Despite findings that support the implementation of routine alcohol screening and demonstrate its advantages, the rate of alcohol screening in health care settings remains lower than 50 percent, as several studies have noted. For example, Diagnostic and Statistical Manual, Third Edition, Revised [DSM–III–R]) were slightly more likely to have been asked about their alcohol use, but none of the patients who met current criteria for alcohol dependence were referred to a peer-support group, such as Alcoholics Anonymous, or to alcohol treatment. In another study, researchers assessed a sample of 972 adults in 2 rural primary care practices on their alcohol use , and brain damage. Routine alcohol screening and early treatment of withdrawal will minimize the development of such complications.To increase alcohol screening rates in clinical settings, physicians must be encouraged to change their practice routines to include screening for every patient. Routine screening for all patients, however, involves overcoming barriers and issues in health care systems that currently block the way, such as the following:Insufficient training in medical school and residency.—Asking patients about sensitive lifestyle issues, such as their alcohol use, requires strong doctor-patient communication skills. Many physicians have not received skills training in this area.Shortage of role models.—Most physician groups have few role models with expertise in the alcohol field. However, difficult clinical areas, such as alcohol use disorders, require respected leaders to champion the cause and promote change.Lack of performance feedback.—Physicians do not routinely receive feedback on their performance regarding alcohol-related problems, because managed care companies and other health care systems have not made this area a priority.Inadequate standards of care.—Standard medical practice does not include obtaining an alcohol use history for every patient. In addition, quality assurance committees and accreditation groups have not penalized or cited physicians or health care institutions for having low rates of alcohol screening.Inflexible clinic systems.—Health care settings are complex systems that can be difficult to change. The introduction of a new clinical procedure, such as routine alcohol screening, requires a commitment by the entire clinic.Several strategies have been found to be effective in promoting the use of screening procedures for other medical problems  in health care settings. These strategies can be classified into the following five general categories:Group education sessionsEducation by respected colleagues Performance feedbackEducational outreach to individual physicians Financial incentives or penalties.Often, a combination of these types of strategies is used. Although their efficacy when applied to alcohol screening has not been widely tested, these strategies appear to offer a promising opportunity for the field. This article discusses each of the five types of strategies and presents reports of their effectiveness in other medical fields and in the alcohol field when available.Courses, seminars, and workshops on screening practices and procedures are sometimes offered to groups of health care professionals. These educational opportunities are used to increase the rates of routine screening in clinical practice. Group education sessions can vary in their effectiveness, however, depending on their structure and content. Effective group education strategies include the following:Onsite educational programs at the physician’s clinic or hospitalSpecific, step-by-step, evidence-based, clinical protocolsPeer group discussionSkills-based role-playingCredible experts delivering the training sessions.Combining an educational program with some of the other intervention strategies presented later in this article  also increases the program’s effectiveness . The NatNumerous researchers have examined the efficacy of group education in changing physician behavior and in its subsequent effects on improving patient health. A study by Educational programs conducted for health care professionals on alcohol screening should incorporate the findings of all these reports. In particular, role playing can be an invaluable way to teach physicians how to become more comfortable with alcohol screening questions and interview techniques by allowing them to rehearse their skills before they interact with their patients. Because nothing can substitute for practice and repetition, role playing with colleagues, standardized patients , or people in recovery can build a physician’s confidence in his or her alcohol-screening skills. For example, role playing can help physicians learn to focus as much on what patients do not say  as what they do say when questioned about their alcohol use. Trainers can facilitate role playing in a small group, or if the group is large, trainers can use a paired role-play technique in which participants role play with the person sitting next to them.Opinion leaders are respected colleagues who are trusted sources of clinical information. These leaders can be local physicians or colleagues known as experts at a State or national level. Often they are trained in the same specialty as the physicians to whom they are speaking.The presentation of new information involving changes in clinical practice can be very effective when conducted by a trusted colleague. This effectiveness was demonstrated by a study done in the obstetrics field, in which the researchers performed a randomized, controlled trial with 76 physicians in 16 community hospitals to increase rates of vaginal births in women with previous histories of cesarean sections . The triThe use of respected colleagues as opinion leaders has special importance for the alcohol field, where societal and health care system barriers may impede the incorporation of alcohol screening into routine clinical care. Opinion leaders can help overcome these barriers by legitimizing and providing the scientific rationale for implementing alcohol-screening procedures. In addition, these leaders can counter societal biases and attitudes that place a lower value on spending health care resources for a so-called self-inflicted problem. Just as opinion leaders in the cardiology field can justify large expenditures to prevent and treat smoking-induced heart disease, opinion leaders in the alcohol field can provide the rationale for the prevention and treatment of alcohol use disorders.One of the most promising developments in the alcohol field is the expanding number of faculty in primary care, obstetrics, emergency medicine, and surgery who are teaching their colleagues how to screen for alcohol problems. Opinion leaders such as these faculty members can play a major role in educating physicians and facilitating changes in physicians’ alcohol-screening practices. Although research on the effectiveness of using opinion leaders to change behavior is limited, this strategy appears to have potential.Changing a physician’s clinical behavior is not an easy process; however, providing feedback is one of the most powerful methods available, especially when a physician perceives a need for change in clinical care. According to Researchers in various health fields have evaluated feedback as a tool for changing physician behavior. Through more than 30 years of research, Reductions in the length of hospital staysReductions in the number of medications prescribed to outpatientsReductions in the number of outpatient tests orderedIncreased compliance with guidelines Reductions in laboratory and total hospital costs.Other studies suggest additional approaches to providing feedback. A report by As suggested in this brief review of the literature, the provision of feedback can change physician behavior and clinical practice. Academic detailing refers to clinic-based educational activities focused on individual practitioners. These educational activities involve outreach visits to offer short didactic presentations to physicians, skills training through role playing, performance feedback, or discussions on pertinent topics . Studies have focused on a variety of health care professionals, such as physicians, nurses, pharmacists, and health educators, to conduct these office-based outreach visits. In addition, pharmaceutical companies have employed this strategy effectively to encourage physicians to prescribe certain medications.Research suggests that financial incentives are another effective tool for changing clinician behavior. Incentives can be based on a variety of indicators, such as the number of patients immunized, the frequency of screening for a selected health problem , the number of prescriptions written for selected medications , the number of patients referred to specialty care, or the number of patients hospitalized. Positive incentives can include bonuses, higher base salaries, or increases in the negotiated rate a managed care organization pays physicians per enrolled patient . These types of incentives can be powerful motivators. For example, Negative financial incentives  also produce changes in behavior, as found in another study by Although additional research in this area is warranted, one can reasonably assume that creating financial incentives for physicians could be applied to the alcohol field to facilitate the implementation of alcohol-screening procedures. As an example, managed care companies could review medical records and provide a year-end bonus to physicians who screened a predetermined percentage of patients for alcohol problems in the preceding year.To incorporate routine alcohol screening efficiently, physicians can adapt a comprehensive clinic-based program similar to the programs used to screen for other health concerns, such as high blood pressure, cancer, elevated cholesterol levels, and tobacco use. In many clinical practices, screening for these health concerns already has become a routine element of care and usually includes procedures such as patient questionnaires, physical measurements or laboratory tests, manual or computerized reminder systems to ensure a thorough examination and assist with followup, standardized prevention messages, and protocol-driven treatment methods.Clinic-based systems acknowledge the complexity of implementing a new activity into a busy practice and the need to systematize the activity as part of routine care. In addition, a clinic-based system requires the active participation of all staff members, not just the individual clinician responsible for questioning the patients. Front-desk staff, for example, often distribute questionnaires and attach reminder printouts to patient charts. Nurses score the questionnaires and follow established protocols designed to manage positive and negative responses. Medical record clerks record the information in the charts and in databases. Physicians then use the data for clinical decisionmaking.The effectiveness of clinic-based systems has been an active area of research since the early 1980’s . For exaFor alcohol screening, a comprehensive clinic-based program could include the following components:Questionnaires administered to patients by the receptionist or nurse, preferably with the alcohol questions embedded among general health questionsA readily available assessment tool, such as one of the instruments discussed in the next sectionA computerized reminder system maintained by clerical staff to prompt clinicians to screen patients for alcohol use disorders or to follow up on previous treatment recommendationsA list, which is periodically updated by clerical staff, of alcohol specialists, peer-support meetings , and community support agencies.Although the ultimate goal is to provide alcohol screening for all patients, screening in clinical settings could initially focus on particular high-risk groups, such as patients who are pregnant, suffering traumatic injuries, or receiving medication for high blood pressure or depression. Alcohol screening also could serve as one component of several targeted health issues, such as breast cancer or tobacco use screening.Several alcohol screening instruments with good accuracy are available for use in health care settings, including the instruments discussed here and in the related article by Cherpitel (see pp. 348–351). Each screening instrument has particular strengths and weaknesses and varies in its applicability to clinical settings. When selecting a screening procedure for routine implementation, clinicians and health care systems should consider factors such as the goals of the screening process, the target population , intervention options, clinician training needs, and costs.The physicians’ guide developed by NIAAA recommends quantity/frequency and binge-drinking questions  as the primary screening test . These qWhen screening patients for current or lifetime alcohol dependence, NIAAA’s physicians’ guide recommends using the CAGE questions . As many as 50 percent of at-risk drinkers will not be identified if questions are limited to the four components of the CAGE test, however . To avoiSome alcohol-screening instruments work best with specific patient populations. Health care systems that primarily focus on women, for example, may want to use the TWEAK test  or a similar instrument, such as T-ACE, that has been designed and tested specifically for use with women. Emergency-care clinicians should consider using the Rapid Alcohol Problems Screen (RAPS), which appears to have advantages over other screening methods when applied in emergency-care settings.Regardless of which alcohol screening instrument is selected, clinicians also may want to establish a brief assessment procedure for patients who screen positive. Examples of pencil-and-paper assessment tools for use in general health care settings include the 10-question Alcohol Use Disorders Identification Test, the 25-question Michigan Alcohol Screening Test, and the 15-question Short Alcohol Dependence Data Questionnaire . CliniciA positive alcohol screen can have enormous implications for a patient, possibly affecting his or her employment status, ability to obtain insurance, and status in the community. Therefore, clinicians should diagnose an alcohol use disorder with the same caution used to diagnose other medical problems.The U.S. health care system provides a great opportunity to identify the majority of people adversely affected by alcohol use disorders. Several specific and sensitive screening tests are available to help clinicians implement routine alcohol screening in their practices. In addition, brief intervention trials have found that simply asking questions about alcohol use can reduce levels of drinking . The chaThe incorporation of routine screening and treatment for high blood pressure and high cholesterol levels in the 1980’s did not occur in the U.S. health care system until research demonstrated that screening for these conditions reduced the frequency of illnesses and deaths . AlthougChanging physician behavior is a complex endeavor not to be taken lightly. The process of change is similar to changing a patient’s behavior regarding alcohol use—knowledge and education are not enough. Educational endeavors must be expanded in medical schools, residency training sites, and CME programs to include role playing and skills-based workshops on alcohol screening. In addition, new physicians should be tested on their alcohol-screening skills as part of the requirement for graduation from medical school and residency. Standards of care also must change so that all patients admitted to hospitals and seen in outpatient clinics are screened for alcohol use disorders just as they are screened for high blood pressure, tobacco use, and high cholesterol levels. Accreditation groups  have the opportunity to require routine alcohol screening and adequate training for students and residents.Although alcohol screening for all patients is not yet the current standard of care, the acceptance of routine screening nevertheless has come a long way over the last 20 years, as the following examples demonstrate:Most medical schools and residency programs now provide educational programs on alcohol screening.Many hospitals are developing alcohol consulting services.Most health forms given to new patients in hospitals and outpatient clinics, as well as many nursing intake forms, now include alcohol-screening questions.Screening all pregnant women for alcohol use is becoming the standard of care in many areas of the country.Some managed care companies are beginning to include  specialized alcohol treatment services under primary care in order to facilitate referral and communication.More than a dozen brief intervention clinical trials currently being supported by NIAAA should provide evidence to convince the managed care industry that alcohol screening and brief intervention are cost-effective.The number of medical school faculty who work in the alcohol area continues to increase.By applying the knowledge and experience gained in changing physician behavior and systems of care in other areas of medicine, the goal of routine alcohol screening for all patients in the U.S. health care system appears to be within reach.


Retinal ganglion cells (RGCs) relay ~40 parallel and independent streams of visual information, each encoding a specific feature of a visual scene, to the brain for further processing. The polarity of a visual neuron’s response to a change in contrast is generally the first characteristic used for functional classification: ON cells increase their spike rate to positive contrast; OFF cells increase their spike rate for negative contrast; ON-OFF cells increase their spike rate for both contrast polarities. Suppressed-by-Contrast (SbC) neurons represent a less well-known fourth category; they decrease firing below a baseline rate for both positive and negative contrasts. SbC RGCs were discovered over 50 years ago, and SbC visual neurons have now been found in the thalamus and primary visual cortex of several mammalian species, including primates. Recent discoveries of SbC RGCs in mice have provided new opportunities for tracing upstream circuits in the retina responsible for the SbC computation and downstream targets in the brain where this information is used. We review and clarify recent work on the circuit mechanism of the SbC computation in these RGCs. Studies of mechanism rely on precisely defined cell types, and we argue that, like ON, OFF, and ON-OFF RGCs, SbC RGCs consist of more than one type. A new appreciation of the diversity of SbC RGCs will help guide future work on their targets in the brain and their roles in visual perception and behavior. Suppressed-by-Contrast (SbC) Retinal ganglion cells (RGCs) were first discovered in 1967 in the cat Rodieck, , rabbit SbC RGCs were only recently identified in the mouse retina; in 2015 two research groups presented an RGC that exhibited contrast suppression profiles, and both groups claimed to have found the SbC RGC in the mouse retina , Zhu et al.  where an associated AC was labeled but SbC RGCs were not.While the CCK-cre is the only transgenic line that contains fluorescently-labeled SbC RGCs that could be directly targeted, other studies non-genetically targeted SbC RGCs strictly by their physiology and morphology in transgenic lines, where SbC RGCs were not fluorescently labeled, but various amacrine cells (ACs) were labeled. In a different study performed concurrently to that of Jacoby et al.  and TienMorphology is a critical component in identifying distinct types of RGCs. This includes characteristics such as size of the dendritic area, diameter of the soma, stratification profile in the inner plexiform layer (IPL) and branch density  of its dendritic length between strata. In comparison, the ON delayed RGC , and those authors confirmed the identify of type “73” as the ON delayed RGC  would yield an ON contrast response profile in the RGC’s spiking response, so inhibition must play a critical role in contrast suppression. Both SbC RGC types had a large inhibitory conductance at light onset that dominated the small excitatory conductance to yield a net hyperpolarization and decrease in spiking, but the ON inhibition differed in both kinetics and pharmacology between the two SbC RGC types. SbC sustained RGCs had a sustained inhibitory current that extended throughout the entirety of a 1 s light step Figure , while OA and/or GABAC receptors (53%) and glycine receptors (47%; Jacoby et al., Inhibition at light onset in the SbC sustained RGC was driven by both GABANot only were synaptic inputs identified, but specific presynaptic AC types were confirmed as sources of inhibition to help shape the contrast suppression profiles of SbC RGCs. Jacoby et al.  identifiBoth Tien et al.  and Lee SbC RGCs respond to increases and decreases in illumination by decreasing their baseline firing rate, and like the traditional ON, OFF, and ON-OFF response polarity classes, functional distinctions within the SbC class depend on characteristics like response kinetics. Along with the rapid identification of these two SbC cell types in mouse retina, the three groups working on these cells also revealed some of the ACs responsible for the SbC computation.We provided evidence that this SbC cell class is comprised of at least two distinct cell types. A highly-sustained SbC RGC type was identified in wild type mice by Jacoby et al.  and has It is possible that other types of SbC RGCs exist in the mouse retina. Just as has been shown in the ON, OFF, and ON-OFF polarity classes, SbC RGCs may each fill a specific niche in kinetics and perhaps other parameters such as stimulus size, motion speed and color.JJ and GS conceived this manuscript idea, wrote the manuscript and created the figures.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.


Parkinson’s Disease (PD) is a prototypical basal ganglia disorder. Nigrostriatal dopaminergic denervation leads to progressive dysfunction of the cortico-basal ganglia-thalamo-cortical sensorimotor loops, causing the classical motor symptoms. Although the basal ganglia do not receive direct sensory input, they are important for sensorimotor integration. Therefore, the basal ganglia dysfunction in PD may profoundly affect sensory-motor interaction in the cortex. Cortical sensorimotor integration can be probed with transcranial magnetic stimulation (TMS) using a well-established conditioning-test paradigm, called short-latency afferent inhibition (SAI). SAI probes the fast-inhibitory effect of a conditioning peripheral electrical stimulus on the motor response evoked by a TMS test pulse given to the contralateral primary motor cortex (M1). Since SAI occurs at latencies that match the peaks of early cortical somatosensory potentials, the cortical circuitry generating SAI may play an important role in rapid online adjustments of cortical motor output to changes in somatosensory inputs. Here we review the existing studies that have used SAI to examine how PD affects fast cortical sensory-motor integration. Studies of SAI in PD have yielded variable results, showing reduced, normal or even enhanced levels of SAI. This variability may be attributed to the fact that the strength of SAI is influenced by several factors, such as differences in dopaminergic treatment or the clinical phenotype of PD. Inter-individual differences in the expression of SAI has been shown to scale with individual motor impairment as revealed by UPDRS motor score and thus, may reflect the magnitude of dopaminergic neurodegeneration. The magnitude of SAI has also been linked to cognitive dysfunction, and it has been suggested that SAI also reflects cholinergic denervation at the cortical level. Together, the results indicate that SAI is a useful marker of disease-related alterations in fast cortical sensory-motor integration driven by subcortical changes in the dopaminergic and cholinergic system. Since a multitude of neurobiological factors contribute to the magnitude of inhibition, any mechanistic interpretation of SAI changes in PD needs to consider the group characteristics in terms of phenotypical spectrum, disease stage, and medication. Back in 1985, Lidsky introduced the notion that the basal ganglia serve as “sensory analyzer for motor systems” which “ultimately affect movement by gating sensory inputs into other motor areas”  is a neurodegenerative disorder affecting multiple neuromodulatory transmitter systems Barone, . The carKEY CONCEPT 1Sensorimotor integration is the process whereby somatosensory input is integrated by the central nervous system to shape motor program execution. Parkinson’s disease (PD) is considered a pathological model of aberrant sensory-motor integration, where movement accuracy and speed are severely affected by the altered sensory feedback.In addition, PD patients also exhibit impairment of selecting the appropriate response while simultaneously suppressing inappropriate response tendencies  was coined for this conditioning-test paradigm, and SAI soon became a well-established neurophysiological technique to probe rapid intracortical sensorimotor integration in health and disease . In their seminal study, Tokimura et al.  demonstrKEY CONCEPT 2in vivo by examining the effects of sensory input on the motor output at the cortical level. The amplitude of a motor evoked potential (MEP) induced by transcranial magnetic simulation (TMS) over the motor cortex is reduced by a peripheral nerve stimulation few milliseconds before the TMS pulse. The magnitude of this inhibition represents the neurophysiological correlate of sensorimotor integration efficiency.Fast component of sensorimotor integration can be studied The neurophysiological and neuropharmacological properties of SAI have motivated researchers to use SAI as a tool to examine whether and how PD is associated with an impairment of fast sensory-motor integration in the pericentral sensorimotor cortex. In the same vein, researchers have examined whether the attenuation of SAI in individual patients scales with dopaminergic and cholinergic cortical neurodegeneration and is associated with particular clinical symptoms  in the corticospinal tract  at 20 Hz completely abolished SAI in the relaxed muscle  of 25 ms .Beyond cholinergic transmission, the dopaminergic system plays a relevant role in the modulation of SAI, in accordance with a strong synaptic interaction between dopamine an acetylcholine signaling in different brain areas  evoked by stimulation of the peripheral nerve. Most SSEP studies in PD have employed electrical stimulation of a mixed nerve that reflects activation of proprioceptive as well as cutaneous inputs. SSEP studies in patients with PD found a reduced amplitude of the late N30 component of the SSEP, while the early N20-P25 components were found to be normal , Multisystemic Atrophy or Cortical Basal Syndrome], or dystonia not including PD population as control group.This search resulted in 22 studies on the final search on November 2, 2018 , 2. FourImportantly, these studies found consistent reduction of SAI mainly in medicated PD patients, whereas the off state was not associated with SAI alterations. The idea that nigrostriatal dopaminergic denervation does not reduce SAI or might even enhance cortical inhibition is supported by two studies. The first one, a small study on three drug-free patients with pure hemiparkinsonism  and with the mean SAI across all five interstimulus intervals . Overall, the results suggest that the attenuating effect of medication state on SAI is more pronounced in patients in whom dopamine replacement therapy shows limited efficacy to normalize parkinsonian motor symptoms as indicated by high UPDRS scores in the on-medication state. It is conceivable that patients who show a less favorable response to dopamine replacement therapy may also have more cholinergic deficits and hence the reduction in SAI may, at least in part, resulting from a co-existing cholinergic deficit at the cortical level. Interestingly, patients with atypical parkinsonism  that usually respond insufficiently to dopaminergic medication, might exhibit reduced levels of SAI  and were normalized by chronic STN-DBS, likely through long-term plastic changes in the basal ganglia thalamocortical circuit  of the main cholinergic system nuclei, would reveal a structure-function relationship between SAI changes and structural cholinergic denervation. The introduction of new PET radioligands, such as (18 F) fluoroethoxybenzoyesamicol [(18 F) FEOBV], a ligand which shows a high affinity for the vesicular acetylcholine transporter, will enable the researcher to simultaneously examine functional changes of the cholinergic systemAll authors prepared the manuscript draft and approved the final manuscript.HS has received honoraria as speaker from Sanofi Genzyme, Denmark and Novartis, Denmark, as consultant from Sanofi Genzyme, Denmark and as senior editor (NeuroImage) from Elsevier Publishers, Amsterdam, Netherlands. He has received royalties as book editor from Springer Publishers, Stuttgart, Germany. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Studies have shown that long-term alcohol abuse produces serious, harmful effects on a variety of the body’s organ systems. Parts of the human body most affected include the liver and the immune, cardiovascular, and skeletal systems. Current research has examined some of these effects in an effort to better understand the medical consequences of alcohol use and abuse and to ultimately develop more effective treatments for responding to alcohol-induced bodily damage. This article discusses some of those findings. Long-term alcohol abuse is known to exert harmful effects on a number of the body’s organ systems. Those most affected by alcohol abuse include the liver and the immune, cardiovascular, and skeletal systems. Many of the mechanisms involved in alcohol’s effects on these systems are not yet completely understood. Consequently, recent research has examined some of alcohol’s medical consequences in an effort to increase understanding and develop appropriate and effective treatments.The liver is a vital organ involved in processing fats, sugars, proteins, and vitamins and in regulating blood clotting. It plays a central role in the body’s defenses, filtering toxins and microbes from the blood and marshaling an array of responses to trauma, stress, or inflammation.Although the liver is capable of regeneration and repair, severe liver disease can be life threatening. Long-term, heavy alcohol use is the leading cause of illness and death from liver disease in the United States. The number of persons with alcoholic liver disease (ALD), which ranges in severity from fatty liver to end-stage cirrhosis, is conservatively estimated at more than 2 million. Women, compared with men, develop alcoholic hepatitis and alcoholic cirrhosis after fewer years of drinking and from ingesting smaller daily amounts of alcohol. Rat studies confirm greater liver damage in females than in males at the same blood alcohol concentration (BAC).There are three forms of ALD: fatty liver, which is usually reversible with abstinence; alcoholic hepatitis, characterized by persistent liver inflammation; and cirrhosis, characterized by progressive scarring of liver tissue. A person can have more than one type of liver disease. Patients with both cirrhosis and alcoholic hepatitis have a death rate of more than 60 percent over a 4-year period, with most deaths occurring within the first 12 months of diagnosis.The major problem in developing new therapies for ALD has been a lack of understanding of the mechanisms for liver injury. However, much has been learned recently as a result of better technology and advances in research.Long-term alcohol consumption has been shown to prolong the natural inflammatory responses of the liver. Inflammation functions to prevent the spread of localized injury or infection while mobilizing the defense mechanisms of the immune system. An important aspect of liver inflammation is the production of chemical messengers called cytokines, which help regulate the inflammatory process. Cytokines attract and activate cells of the immune system, promote scar formation, and stimulate the production of additional chemical messengers, including more cytokines. However, if the increased levels of cytokines do not subsequently return to normal, they can cause chronic inflammation, leading to cell injury or cell death.Cytokine production can be stimulated by endotoxin, a substance derived from the cell walls of certain bacteria that reside in the human intestine. Heavy alcohol consumption can increase the passage of endotoxin through the intestinal wall into the bloodstream. Specialized immune system cells  in the liver respond to blood-borne endotoxin by producing inflammatory cytokines. These cytokines further increase gut permeability, perpetuating a destructive cycle.Another stimulus for excessive cytokine production is the generation of reactive oxygen species (ROS), toxic by-products of alcohol metabolism in the liver. Normally, ROS are quickly inactivated by antioxidants, protective molecules such as glutathione and vitamins A and E. However, if these defenses are impaired or if there is an overproduction of ROS, the result can be destruction of cell components and eventual cell death.Persistent liver inflammation is characteristic of alcoholic hepatitis and usually precedes alcoholic cirrhosis. The hallmark of cirrhosis is cytokine-induced scarring that distorts the liver’s internal structure and impairs its function. Imbalances in cytokine interactions impair the normal regeneration of tissue that typically follows liver injury.Researchers have devised several strategies to prevent or minimize alcoholic liver damage. In experiments using rats, alcohol-induced liver injury has been lessened by suppressing endotoxin-producing intestinal bacteria ; administering substances that selectively destroy Kupffer cells or that inhibit the generation of ROS; and feeding antibodies that neutralize specific cytokines.Experiments with a soybean extract, polyenylphosphatidylcholine (PPC), showed that it could prevent fibrosis and cirrhosis in alcohol-fed baboons. It also reduces the formation of scar tissue and may possess antioxidant properties as well. A study conducted by the U.S. Department of Veterans Affairs is currently evaluating the effects of PPC in humans with early ALD. Therapy with S-adenosyl-l-methionine (SAM) may lessen the depletion of the antioxidant glutathione in liver cells. Choline and methionine, dietary factors related to SAM, may help protect against endotoxin-induced liver injury in rats.For 200 years physicians have observed that excessive alcohol consumption can lead to increased illness and death from infectious diseases. Alcohol abusers suffer from increased susceptibility to bacterial pneumonia, pulmonary tuberculosis, and hepatitis C (HCV). Patients with ALD are at high risk of having HCV, the leading cause of liver transplantation in the United States . FindingAlcohol abusers may be at increased risk compared with nonabusers for infection with human immunodeficiency virus (HIV) from risky sex practices while intoxicated. Researchers also are investigating whether alcohol consumption itself may increase susceptibility to HIV infection or hasten the progression from HIV infection to full-blown AIDS.In addition, some alcohol-related organ damage, as in ALD, may result in part from immune system overactivity in which the immune system attacks the body’s own tissues . Current research is examining the effects of heavy drinking on the immune system.The body’s first line of defense against disease is inflammation, as described earlier. Inflammation is a nonspecific response, directed against all sources of damage. When nonspecific defenses are breached, an array of specific immune responses see  come intPhagocytes are specialized cells that engulf invading microorganisms and cell debris through a process called phagocytosis. The first phagocytes to be activated are macrophages, which reside in tissues and organs throughout the body. White blood cells infiltrate the area, with neutrophils (a type of phagocyte) being the first to arrive, followed by monocytes. Monocytes are one of the types of cells that initially determine the “foreignness” of an invading agent and present it to other cells, which respond by producing appropriate cytokines. Various immune cells release chemical messengers to attract more cells, and within neutrophils and macrophages, the toxic oxygen-containing compounds ROS destroy phagocytosed microorganisms. Excess ROS, however, can damage liver cells.Throughout the immune response, cytokines continue their regulatory functions. They include tumor necrosis factor (TNF) and a family of both inflammatory and anti-inflammatory substances called interleukins.Both chronic and acute alcohol administration can produce the loss of various types of immune responses in experimental animals. Administration of alcohol concentrations similar to those seen in binge drinkers impairs the function of cultured human monocytes and can temporarily reduce the numbers and activity of immune cells in mice. Alcohol inhibits neutrophil migration in humans and in experimental animals. However, an infiltration of neutrophils into the liver is observed in alcoholic hepatitis. Experiments with alcohol-fed rats showed that their neutrophils engulfed bacteria efficiently but did not kill all strains of pneumonia-causing bacteria with normal effectiveness.Although inflammatory cytokine levels increase in ALD, endotoxin-induced secretion of inflammatory cytokines in the lung may decrease in alcohol-fed animals as well as in human alcoholics, potentially increasing susceptibility to pneumonia. Acute administration of alcohol to rats reduced ROS production by isolated lung macrophages after challenge with TB organisms.Some proposed therapies include administration of such substances as antibodies against endotoxin or against specific cytokines, substances that would absorb excess cytokines or inhibit their function, and drugs that have a widespread effect . Administration of growth hormone and related chemical messengers has been shown to improve some, but not all, measures of immune function in rats.Chronic heavy drinking is a leading cause of cardiovascular illnesses such as degenerative disease of heart muscle (cardiomyopathy); disorders associated with decreased blood supply to the heart muscle (coronary heart disease [CHD]); high blood pressure; heart rhythm disorders (arrhythmias); and stroke.Long-term heavy drinking can cause the heart to become enlarged and lose some of its ability to contract, a condition known as alcoholic cardiomyopathy. These symptoms include shortness of breath and an insufficient blood flow to the rest of the body. Women may have a greater risk than men of developing alcoholic cardiomyopathy. The condition may be at least partially reversible with abstinence.Alcohol’s toxic effects on heart muscle may be mediated by increased ROS levels and decreased antioxidant enzyme activity. Another recent study found that alcohol may decrease the sensitivity of heart muscle to chemical messengers from nerve cells that regulate heart muscle metabolism and contraction.The blood that nourishes the heart muscle is delivered through the coronary arteries. Manifestations of CHD range from episodic chest pain to sudden death. Heart attacks, the most common serious manifestation of CHD, are usually triggered by the formation of a blood clot within a coronary artery already narrowed by deposits of cholesterol and other fatty substances. The resulting ischemia reduces the heart’s pumping ability, often leading to permanent disability or death.With few exceptions, worldwide epidemiologic data demonstrate a 20- to 40-percent lower CHD incidence among drinkers compared with non-drinkers. Heavy drinkers have an increased risk of death from heart disease. However, moderate drinkers exhibit lower rates of CHD-related mortality than both heavy drinkers and abstainers. This is confirmed by studies in which participants were interviewed about their drinking habits and life styles before the onset of disease. Such studies—representing a total population of more than 1 million men and women of different ethnicities followed for up to 24 years—confirm an association between moderate drinking and lower CHD risk. However, this association does not necessarily mean that alcohol itself is the cause of the lower risk.In addition, different epidemiologic studies apply the term “moderate drinking” to a wide range of consumption levels, sometimes more than the amount defined by the Dietary Guidelines for Americans as moderate: two or fewer standard drinks per day for men and one or less per day for women. In any case, the apparent benefits of moderate drinking on CHD mortality are offset at higher drinking levels through increasing risk of death from other alcohol-related causes.Research has suggested several possible mechanisms by which alcohol may protect against CHD. For example, alcohol inhibits the deposition of fatty substances within the coronary arteries of mice and also may inhibit the formation of blood clots within already narrowed coronary arteries.Epidemiologic data and results of studies on isolated animal hearts suggest that moderate alcohol consumption also may lower CHD mortality by improving survival after a heart attack. Further studies are needed to confirm this effect and to determine its applicability in humans.An association between heavy alcohol consumption and increased blood pressure has been observed in more than 60 studies in diverse cultures and populations. The effects of moderate alcohol consumption on blood pressure are unclear.The heart’s ability to function effectively depends on regular, synchronous contraction of the heart muscle. Heavy drinking can disrupt the heart rhythm both acutely (during an episode of drinking) and chronically (due to long-term use). Intoxication can cause certain types of arrhythmia in both alcoholics and otherwise healthy persons. The development of arrhythmias with binge drinking—a condition seen most frequently around the holidays—is known as “holiday heart syndrome.”Sudden death attributable to arrhythmia is one of the causes of mortality in alcoholics with or without pre-existing heart disease. Such deaths often occur during periods of abstinence , suggestThe relationship between alcohol consumption and stroke is similar to that seen with CHD. Moderate alcohol consumption appears to be associated with lower incidence of ischemic strokes, whereas heavy drinking may increase the risk of both ischemic and hemorrhagic strokes .Epidemiologic studies have found a significant association between alcohol consumption and risk for bone fracture. In addition to increased risk of accidental injury through alcohol-induced impairment of gait and balance, alcoholics also may suffer from a generalized decrease in bone mass, making their bones more fragile. Heavy drinking may lead to osteoporosis, characterized by severe back pain, spinal deformity, and increased risk of wrist and hip fractures, although some recent studies suggest that moderate alcohol consumption may protect against osteoporosis.Bone growth and remodeling during childhood and adolescence involves the coordinated activity of two types of cells: (1) osteoclasts, which break down  bone, and (2) osteoblasts, which form new bone.Cyclic bone remodeling continues throughout adulthood to regulate and maintain bone mass. Adult bone formation and resorption rates are tightly coupled, with approximately 10 percent of bone undergoing the process at any given time. Between ages 20 and 40, a person’s bone density begins to decline, resulting in a cumulative decrease in skeletal mass of up to 40 percent by age 70. Women experience accelerated decline in bone density following menopause and are more susceptible than men to osteoporosis.Alcohol disrupts bone remodeling in animals and humans. Overall, studies in alcoholics suggest that alcoholic bone disease involves considerable suppression of bone formation with essentially normal rates of resorption. The changes in bone turnover induced by alcohol can apparently be reversed by abstinence. The skeletal consequences of alcohol intake may be especially harmful during adolescence, when the rapid skeletal growth ultimately responsible for achieving peak bone mass occurs. By limiting peak bone mass attainment, the risk of developing osteoporosis later in life may increase and its onset hastened.Long-term consumption of alcohol disrupts the processes of bone growth and bone tissue repair. A decrease in bone density, as well as an increased risk of bone fracture, may result. These effects of alcohol on bone may occur directly, with alcohol itself interfering with bone metabolism, or indirectly, with alcohol exerting its effects through a third party, such as hormones. The female reproductive hormone estrogen appears to affect bone metabolism, although its role with respect to alcohol consumption is uncertain.A number of researchers have noted that alcohol can reduce osteoblast formation. Alcohol can inhibit osteoblast proliferation in culture at concentrations well within the drinking level observed in alcoholics. A concentration of alcohol equivalent to a blood alcohol level of 0.044 percent, about half the blood alcohol level that many States define as legally intoxicated, also resulted in a 20-percent decline. Alcohol also may depress osteoblast function by inhibiting the cell’s response to insulin-like growth factors, chemical messengers that help regulate bone remodeling.Studies of alcohol’s effects on osteoclast numbers have provided conflicting results. However, alcohol increases levels of a specific interleukin (IL-6), which may contribute to the development of osteoporosis by stimulating osteoclastic activity.The lifetime risk for breast cancer among U.S. women is estimated to be as high as one in eight. Results of approximately 50 epidemiologic studies and analyses conducted since the 1970s point to an increase in breast cancer risk associated with alcohol consumption. Controversy remains over the interpretation of these studies, however. For epidemiologists, the actual numerical association between alcohol and breast cancer risk is considered relatively modest. In addition, some studies found no link between high alcohol intake and breast cancer risk.Scientists have identified plausible biological mechanisms for alcohol’s actions. Research findings suggest a role for alcohol in breast cancer risk in both premenopausal and postmenopausal women. Cumulative lifetime exposure to estrogen is considered an important contributor to breast cancer risk. A number of studies have examined whether alcohol raises estrogen levels in premenopausal and postmenopausal women. Although some studies report such an effect, the evidence is not conclusive.Alcohol may be capable of enhancing the progression as well as the initiation of cancer. Increased metastasis (proliferation beyond the site of origin) of implanted breast cancer cells was observed in rats given alcohol in a liquid diet. In addition, alcohol and its highly reactive metabolite acetaldehyde also have been linked to the body’s inability to repair damage to the cell’s genetic material  induced by cancer-causing agents. If unrepaired, damage to critical regions of DNA in breast cells could lead to mutations and the subsequent initiation of cancer. When rodents are fed alcohol, their levels of circulating prolactin—a hormone that can stimulate the growth of breast tissue—increase. In addition, ROS can contribute to tumor promotion. Alcohol intake also decreases the immune system’s ability to detect and destroy cancer cells .


The rising epidemic of myopia will have far-reaching consequences for individuals and society unless we provide adequate treatment and care.Good distance vision is important for many activities; for example, recognising someone across the road, driving a vehicle and reading from a blackboard in school. The impact of uncorrected myopia varies depending on the age of the person affected. Those who develop high myopia, defined as ≤ −5 dioptres (D) are at increased risk of cataract, open-angle glaucoma, myopic macular degeneration and retinal detachment (p. 5), all of which has a personal and economic cost.Myopia usually starts to develop after the age of 10 years, but in East Asia it can start earlier. Uncorrected myopia can affect children's ability to learn in school and their quality of life.An important benefit of providing school-aged children with spectacles is enhanced educational outcomes.A randomised controlled trial among 20,000 children in 250 schools in Western China by Ma et al.“Myopia does not only affect educational outcomes; disadvantages arising from myopia also extend to quality of life and personal and psychological well-being.”An important finding in this study was that the beneficial effect of providing spectacles increased when there was a greater use of blackboards (rather than textbooks) for teaching in the classroom; this points to the impact of providing spectacles for myopia, as near-sighted children would be expected to benefit more from spectacles when trying to see a blackboard in the distance rather than a book that was close to them. Providing spectacles also exceeded the average educational impact observed in many other school-based health interventions in low- or middle-income countries, including dosing with iron to correct anaemia, giving vitamins and giving medications to eliminate parasites.These results are consistent with studies of varying designs, suggesting a causal association between better visual acuity and children's academic performance. In a prospective cohort study, Jan et al.Although programmes of free spectacle delivery are shown to increase children's use of spectacles significantly,Myopia does not only affect education outcomes; disadvantages arising from myopia also extend to quality of life and personal and psychological well-being and development, particularly when individuals develop high myopia.Adolescents with vision impairment reported statistically significantly lower quality of life, psychosocial functioning and school functioning scores.Adolescents and younger children can experience social pressures against spectacle wear and may avoid wearing the spectacles they have been prescribed. These pressures have been identified in children across a range of contexts; for instance, children reported being teased or discriminated against (or being afraid of this) in studies from Brazil,Studies from high-income countries have shown that adults with high myopia reported psychological, cosmetic, practical, and financial factors specifically related to myopia that affected their quality of life.In 2015, uncorrected myopia was estimated to have caused $244 billion of potential lost productivity worldwide. Macular degeneration due to myopia was associated with another $6 billion of potential productivity loss.There are very few economic evaluations of myopia correction and no economic evaluation of myopia prevention. However, disability weights have been used to estimate potential productivity loss as a proportion of the gross domestic product (GDP per person).The potential improvements in academic achievement for children who receive myopia correction, along with associated quality of life and psychosocial functioning gains – together with the economic case for myopia treatment in terms of productivity – speak to the need for interventions. However, addressing parents' and children's concerns about wearing spectacles and making efforts to maximise spectacle wear are critical for realising the economic or academic benefits of correcting myopia.


Although the American Council of Graduate Medical Education (ACGME) mandates formal education in patient safety, there is a lack of standardized educational practice on how to conduct patient safety training. Traditionally, patient safety is taught utilizing instructional strategies that promote passive learning such as self-directed online learning modules or didactic lectures that result in suboptimal learning and satisfaction.During the summer of 2015, 76 trainees consisting of internal medicine interns and senior-level nursing students participated in an interactive patient safety workshop that used a flipped classroom approach integrating team based learning (TBL) and interprofessional simulated application exercises.p = 0.001). Completion rates on the simulation application exercises checklists were high except for a few critical action items such as hand-washing, identifying barriers to care, and making efforts to clarify code status with patient. The Readiness for Interprofessional Learning Scale (RIPLS) subscale scores for Teamwork and Collaboration and Professional Identity were higher on the post-workshop survey compared to the pre-workshop survey, however only the difference in the Positive Professional Identity subscale was statistically significant (p = 0.03). A majority (90%) of the trainees either agreed that the safety concepts they learned would likely improve the quality of care they provide to future patients.Workshop trainees demonstrated an increase in knowledge specifically related to patient safety core concepts on the Team Readiness Assurance Test (TRAT) compared to the Individual Readiness Assurance Test (IRAT) (This novel approach to safety training expanded teaching outside of the classroom and integrated simulation and engagement in error reduction strategies. Next steps include direct observation of trainees in the clinical setting for team-based competency when it comes to patient safety and recognition of system errors. Preventable medical errors are the third leading cause of death in the U.S., claiming the lives of over 400,000 patients each year . These nAt Stony Brook University the academic health science schools and hospital share common elements of their missions: to educate and provide excellent quality clinical care. Although there have been successful efforts to promote interprofessional learning and practice, there are still too few opportunities to systematically bring our faculty and trainees from multiple disciplines together in a meaningful way for the purpose of improving the quality of patient care by learning about each other’s roles, cultivating communication, practicing collaboration and fostering teamwork. To address this need, we designed and developed an interprofessional, collaborative, team-based learning simulation experience with the goal of promoting safe and quality patient care among healthcare professional trainees. While interprofessional simulation strategies are becoming more widely used –5, this Medicine has traditionally relied on an apprentice-style approach to learning and experience . This inTeam-based learning (TBL) is an evidence-based, multiphase pedagogical approach that requires active learner/trainee participation and collaboration . This inThe objective of this study was to design, implement, and evaluate the effectiveness of a simulation training model that incorporates interprofessional learning and TBL for interdisciplinary faculty to teach core concepts of patient safety.During the months of July and August 2015, we conducted five 3.5-h interprofessional patient safety-training workshops. These workshops were scheduled during residents’ protected didactic time. At each workshop, trainees  were randomly grouped into pre-determined interprofessional teams consisting of 4–6 trainees per team. The size of each team varied depending on the number of trainees available for the workshop. Each team had either one or two internal medicine residents and between three or four nursing students. Prior to this workshop the trainees had not worked together before and were not given the team assignments in advance. The teams remained together for the duration of the workshop, rotating through all of the clinical simulation scenarios as a unit  was completed by each trainee, followed by an identical Team Readiness Assurance Test (TRAT) that was completed by each interprofessional team. The IRAT/TRAT consists of 10 questions, each question worth 1 point for a total possible score of 10 points. The content of the test is based on patient safety literature contained in pre-reading assignments given to the trainees one week prior to the workshop. A content expert reviewed the IRAT/TRAT for face and content validity. At the end of the TRAT, faculty instructors reviewed the correct and incorrect answers and provided feedback, rationale, and offered clarifications to the trainees. The purpose of the IRAT/TRAT was to hold the trainees accountable for learning the pre-reading materials and to demonstrate understanding of the concepts with their team members in preparation for the simulation case scenarios.Following the readiness assurance process, however, rather than a TBL application-based exercise on paper, the interprofessional teams engaged in three simulations using high fidelity manikins and standardized patients designed to reinforce the workshop learning objectives through hands-on teamwork and communication. These simulation cases included: 1) systematic analysis of a medical error with the use of a high fidelity mannequin, 2) interprofessional I-PASS mnemonic handoff  with theThe simulation training program was evaluated using data collected from trainees on their knowledge, skills, and attitudes. Specifically, patient safety knowledge-based learning outcomes were evaluated using the IRAT and TRAT. The rationale for comparing IRAT and TRAT was to evaluate the contribution to learning from the interprofessional team experience and to provide corrective feedback to the team.In terms of attitudinal data, the Readiness for Interprofessional Learning Scale (RIPLS), a validated 19-item questionnaire developed by Parsell and Bligh , 14, wasThe trainees completed a post-workshop self-assessment survey that we developed that asked them to rate on a scale of 1 (Not Confident at All) to 5 (Very Confident) their confidence level in carrying out the concepts learned during the simulation workshops. Finally, completion rates of the performance checklist for each simulation case allowed trainees to apply and demonstrate hands-on skills of what they have learned from the pre-workshop study materials and then reinforced through the readiness assurance process.t-test was used to compare the overall mean IRAT scores with the overall mean TRAT scores to see if there was a difference between individual and team performances. Chi-square tests were conducted to compare the number of correct responses for each question item between the IRAT and TRAT. Aggregate pre-post responses for the Readiness for Interprofessional Learning Scale (RIPLS) . A significantly higher number of correct responses were selected on the TRAT compared to the IRAT on questions related to these patient safety concepts: preventable adverse events, cognitive biases, and patient handoff communication [The TRAT scores  were significantly higher than the IRAT scores [Mean = 5.6, SD = 1.7; Performance of each interprofessional team on the three simulation/standardized patient application case scenarios was assessed through direct observation by MD and RN faculty instructors using checklists that included critical action items. After each interprofessional team performance, the faculty instructors would immediately discuss what they observed and come to a 100% full consensus on which items were completed by the team. A majority of the critical action items on the checklists were completed by the interprofessional teams (see Table t (140) = − 2.2, p = 0.03)  were higher on the post-workshop survey  compared to the pre-workshop survey , a statistical difference was seen only in the Positive Professional Identity subscale from before  to after the workshop , “their ability to provide proper hand-off using IPASS” (86%), and “their ability to provide a safe discharge plan” (86%).Learning about patient safety requires the understanding of relevant concepts and principles as well as the demonstration of teamwork, communication skills, and error reduction strategies. This study used simulation-based education that integrated two instructional strategies to teach patient safety: team-based learning and interprofessional, collaborative learning. Additionally, the simulation application is centered on commonly encountered medical errors. Simulation is a powerful and frequently used technique that can help healthcare professionals achieve higher levels of competence and safer care . Our stuTeam performance on the TRAT for patient safety knowledge was higher than that of the individual performance on the IRAT. The team-based learning approach was used to ensure that trainees would begin the workshop with a basic understanding of patient safety concepts including systematic analyses of medical errors, effective handoffs, and patient education teach-back techniques. The simulation/standardized patient application case scenarios that followed required the trainees to access and apply patient safety, communication, and teamwork skills. One of the benefits of the TBL approach ensures that misunderstanding and/or lack of understanding of certain concepts at the individual level, is addressed in discussion and peer learning during the team readiness assurance process. Previous research also showed that learners perform better on the TRAT if they complete the IRAT first because learners would need to consider the questions on their own first and therefore feel inclined to contribute to the team discussion to share their thoughts as well as listen to the thoughts of others . This prWe found high completion rates for a majority of the critical safety actions across all interprofessional teams for each case scenario. There were a few action items that were not performed by at least half of the interprofessional teams such as hand washing , clarifying code status with the patient ; and identifying barriers of care with the patient . Additionally, only 55% of the interprofessional teams were able to provide appropriate illness severity and give a patient summary that is concise and relevant. This information can inform health professions educators as they design and develop training programs and curriculum. Hand washing, in particular, is a simple, yet critical, action item that should be continuously emphasized in all areas of simulated training programs, including patient safety curricula.While increases in the RIPLS Teamwork and Collaboration and Professional Identity subscales were noted after workshop participation, the only significant difference occurred in the Positive Professional Identity subscale. According to the definition of each subscale and description of its psychometrics properties provided by Parsell and Bligh , these rThis study has several limitations that include a small sample size from each profession at a single institution and the use of a pre-posttest study design which does not assess the long-term effect of the intervention. Some caution is therefore advised in interpreting the results of this study as these results may not be generalizable to the general population in each profession. Some existing literature also questions the use of the RIPLS instrument and its sensitivity to detect meaningful change over time since researchers frequently find no significant difference between pre-and post IPE intervention . In our Next steps include repeat interprofessional, TBL simulations throughout the course of training, follow-up with trainees to obtain their perspectives on whether this activity has impacted patient care, and direct observation of residents in actual patient care settings including discharge and hand-off experiences. In this way, trainees can be further observed in actual clinical settings for team-based competency in patient safety and recognition of systems errors.Future directions should include the development of patient safety direct observation tools to evaluate whether trainees are applying the learned simulation skills in their clinical practice. These tools can be used to measure skills during routine patient care on clinical units. Patient care events including error disclosure, multidisciplinary meetings, patient discharge meetings, and patient counseling about safety issues may be observed and evaluated.Through interprofessional, TBL simulation, trainees actively participate, engage in, and demonstrate learning concepts related to patient safety. Implementation of such an approach is an important teaching strategy which can increase healthcare trainees’ interest and motivation to learn about key patient safety concepts. This training program will fulfill educational requirements and promote necessary skills among trainees to develop lifelong habits to effectively reduce medical errors. In this study we found that a simulation model in an interprofessional team setting can teach healthcare professionals realistic, hands-on principles of patient safety.


The internet is an increasingly popular tool in family and child research that is argued to pose new ethical challenges, yet few studies have systematically assessed the ethical issues of engaging parents and children in research online. This scoping review aims to identify and integrate evidence on the ethical issues reported when recruiting, retaining and tracing families and children in research online, and to identify ethical guidelines for internet research.Academic literature was searched using electronic academic databases  and handsearching reference lists for articles published in English between January 2006 and February 2016. Grey literature was searched using Google to identify relevant ethical guidelines.Sixty-five academic articles were included after screening 3,537 titles and abstracts and 205 full-text articles. Most articles reported using the internet to recruit participants (88%) with few reporting online retention (12%) or tracing (10%). Forty percent commented on ethical issues; the majority did not discuss ethics beyond general consent or approval procedures. Some ethical concerns were specific to engaging minors online, including parental consent, age verification and children’s vulnerability. Other concerns applied when engaging any research participant online, including privacy and confidentiality, informed consent and disparities in internet access. Five professional guidelines and 10 university guidelines on internet research ethics were identified. Few academic articles (5%) reported using these guidelines.Engaging families and children in research online introduces unique challenges requiring careful consideration. While researchers regarded themselves as responsible for ensuring research is conducted ethically, lack of use of available guidelines and limited academic literature suggests internet research is occurring without suitable guidance. We recommend broad dissemination of ethical guidelines and encourage researchers to report the methodological and ethical issues of using the internet to engage families and children in research. Parents and children in contemporary society are facing new and multiple demands that may affect their wellbeing, and limit parents’ capacity to support their child’s healthy development . High qurecruitment ; retention (strategies to ensure ongoing participant involvement to reduce attrition); and tracing (strategies to find and re-connect with participants who have been lost to follow-up). Conventional approaches to engage families and children in research  are not only expensive and labour intensive ).Three articles discussed the ethical concerns associated with offering incentives in research , 62, 81,Similar to participants, researchers may also be subject to privacy and safety risks when engaging participants online. While several articles reported interacting with participants online, for example via Facebook messaging features or discussion boards, only one study described the potential impact of this on the researcher and how they protected their personal privacy by creating a new Facebook account used solely for contacting participants . AnotherThe academic literature search identified a small number of articles offering ethical guidance when engaging research participants online. This is best illustrated in three case studies , 59, 71 Of the 58 research articles identified in the review, only three , 37, 82 A grey literature search identified a number of guidelines published from January 2006 to February 2016 specific to the ethical conduct of internet research. These included five professional guidelines developed by government bodies, societies and collaborative academic working groups see  and ten Regarding professional guidelines, the most widely cited ethical guidelines for internet research are those published by the AoIR  and the The grey literature search identified other professional guidelines not cited by articles identified in the review. Produced in Australia, Clark et al.  provide The grey literature search identified several universities, predominantly within the USA and UK, providing publicly accessible guidance on the ethical use of the internet in research. The content of the university guidelines varied widely and included comprehensive guidelines e.g., , 109), g, g109]),Other resources describing the ethical issues of online research were also identified in the search. Several book chapters were identified , 95, 111any research participant online, such as protecting participant privacy and confidentiality, obtaining consent and disparities in internet access. Engaging minors online raises additional ethical concerns and considerations, including parental consent, age verification and participant vulnerability. While these issues highlight some overlap between offline and online methods of participant engagement, the ‘visible’, far-reaching and dynamic nature of online platforms, especially social media, can inflate risk and introduce new challenges. Clearly, there are specific nuances of the online environment that the research community should be aware of. However, as highlighted in this review, many research articles do not report the ethical issues associated with engaging research participants online, and few refer to internet-specific ethical guidelines.This review is the first attempt to identify and integrate literature on the ethics of using the internet to engage participants in family and child research. The review is timely in the context of changing communication patterns, increased social mobility and a research environment with limited funding. Communicating via the internet has rapidly emerged as the ‘new normal’ in everyday life; a development that has extended to the research world. Researchers  have a number of ethical concerns when engaging participants online. Some of these apply when engaging The review identified three unique ethical issues to be considered when engaging minors in research online. The first relates to the ethical and practical complexities of obtaining parental consent online. Parental consent serves to respect children’s developing autonomy and to provide for their protection , althougThe second unique issue of verifying participant age was an important yet challenging aspect of engaging minors in research online as young people may misrepresent their age to participate. Articles suggested several strategies to verify age, including directly contacting the participant or their parent. However, depending on the nature and context of the study, this may be inappropriate or unfeasible. Others suggested validating participant age by reviewing social media profiles. This raises further concern for participant privacy and may not be a valid approach if the minor has falsified their age . Articles did not explicitly discuss the ethical implications of inadvertently engaging younger or underage participants in research, despite the potential for them to be exposed to sensitive or age-inappropriate content. Guidance on this issue is mixed: one guideline  suggestsThe third issue identified in the review relates to children’s vulnerability in online research. Young people are often referred to as ‘digital natives’: a younger generation born into a ubiquitous digital environment who have used the internet, social media and mobile devices from an early age . HoweverConcerns were also raised about the possibility of participants, potentially those who are young or vulnerable, unwittingly ‘outing’ themselves as research participants online. This may occur due to a lack of knowledge regarding privacy settings, features and the reach of online platforms. While this may be no different to offline research where participants may disclose their participation to others, the audience is much more far-reaching in the online space and individuals may lose control of their information once they ‘release’ it online. These concerns require researchers to be transparent and openly inform prospective participants about potential risks to their privacy, confidentiality and anonymity online, as suggested by articles included in the review  and in rAn additional issue that received minimal attention in the review but which warrants further discourse is whether participants, particularly minors, are sufficiently informed in online research. One article noted that adolescents were generally uninterested in reading study information and informed consent materials ; an obseDespite recruiting participants online, many articles in this review obtained consent via traditional means . The ongoing reliance on offline consent procedures may reflect concern for participant comprehension in online settings. However, the inability to assess whether participants are truly informed is not confined to online research , and articles often compared the deficiencies of online consent procedures against an idealised view of the communication than can, but often does not occur in face-to-face consent. Articles suggested several strategies to improve participant comprehension online, including video conferencing and phased consent. Some recognised the advantages of obtaining verbal consent and assessing comprehension via telephone, although we question the viability of this approach with large samples and its utility in anonymous research. Emerging evidence indicates that testing adolescents on their research rights and risks during the online consent process can improve study comprehension . FurtherOur review has identified several insights and gaps in the academic literature that are worth noting. Firstly, while researchers have sought new ways to engage participants online, a continued reliance on traditional offline recruitment methods remains. The use of offline and online methods may help overcome technological barriers such as the digital divide but may also reflect uncertainty regarding the effectiveness of solely using the internet. Clear evidence for effectiveness is currently hampered by an absence of, or lack of detail in, reporting the success of recruitment, retention and tracing methods. Reporting ethics approval processes and how consent is obtained online could also be improved. The absence of this information does not ease concerns regarding the validity and credibility of online recruitment and online consent. We encourage researchers to report response metrics and/or recruitment source data as well as consent procedures. Researchers reporting results for internet surveys may wish to refer to Eysenbach’s checklist .Over half of the articles included in the review did not discuss ethical issues beyond general ethical procedures. The limited discussion of ethical concerns aligns with that reported by Henderson et al. , who revWe recognise that many of the ethical concerns identified in this review pertained to online recruitment. Using the internet to retain or trace participants was not as widely used or at least not commonly reported. This could be due to limitations in our search strategy, as articles may not explicitly refer to retention and tracing in their title, abstract or key words. Alternatively, it could reflect the smaller number of longitudinal studies (which require retention and tracing) relative to cross-sectional studies, or that use of the internet in this way is an emerging method not yet in widespread use. Nonetheless, it is surprising that so few retention and tracing studies were identified given the recognised difficulty in maintaining research cohorts in longitudinal research , 138. ItLastly, we show that most researchers do not refer to internet-specific ethical guidelines when reporting online recruitment, retention or tracing methods. Previous research has identified a perception from researchers and ethics committee members that there are few guidelines available to inform internet research . Our revSince conducting our literature searches in early 2016, additional internet-specific guidelines have emerged –147. TheThis review has several limitations. While we searched six academic databases and aimed to be inclusive with terminology, there may be relevant studies and articles that were not captured by the search strategy. For example, articles may describe ethical issues without referring to ‘ethics’ in their title, abstract or key words. Studies using online retention and tracing strategies may also not explicitly report this, as discussed, which may account for the few retention and tracing studies identified. While Facebook is a common research tool, the high proportion of studies using Facebook compared to other social media platforms may be due to this being the only platform specifically named in our search strategy. We recognise articles in other disciplines not included in this review would inform family and child research. We also recognise the limitations of the grey literature search, which was neither exhaustive nor systematic, with results limited to the first 100 hits. Google is not well suited for complex search queries and results are retrieved by popularity; therefore, relevant ethical guidelines may have been missed.This scoping review provides a comprehensive overview of the ethical issues that arise when engaging participants in family and child research online and the available ethical guidance on online research. It serves as a useful resource for researchers and ethics committee members who are considering the ethical appropriateness of research in this context. All in all, using the internet and social media to recruit, retain and trace participants is possible, but must be harnessed appropriately. This requires researchers and ethics committees to be cognisant of a range of ethical issues, including the unique challenges associated with engaging minors online, and to carefully consider how these issues apply when planning, conducting and reviewing research.Our review shows that researchers consider themselves primarily responsible for ensuring internet research is conducted ethically, yet it remains unclear to what extent researchers are aware of and appropriately informed of the specific ethical issues associated with engaging research participants online, particularly minors. Ethical guidelines are essential to consistent and high-quality decision-making, yet the lack of reported use of available guidelines and the scarcity of academic literature describing ethical concerns means research and ethical review are potentially occurring without suitable guidance. Increasing the research community’s understanding of the contextual and ethical challenges of engaging participants online is clearly required. This can be achieved by encouraging broad dissemination and use of current guidelines and resources Click here for additional data file.S2 File(XLSX)Click here for additional data file.