How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and metaregression analysis
Lucy Platt1,
G J Melendez-Torres2,
Amy O'Donnell3,
Jennifer Bradley3,
Dorothy Newbury-Birch4,
Eileen Kaner3,
Charlotte Ashton5
1Department of Social and Environmental Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
2Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
3Institute of Health and Society, Newcastle University, Newcastle, UK
4Health and Social Care Institute, Teesside University, Middlesbrough, UK
5Camden & Islington Public Health, London Boroughs of Islington and Camden, London, UK
Correspondence to Dr Lucy Platt; lucy.platt{at}lshtm.ac.uk
Background While the efficacy and effectiveness of brief interventions for alcohol (ABI) have been demonstrated in primary care, there is weaker evidence in other settings and reviews do not consider differences in content. We conducted a systematic review to measure the effect of ABIs on alcohol consumption and how it differs by the setting, practitioner group and content of intervention.
Methods We searched MEDLINE, EMBASE, PsycINFO; CINAHL, Social Science Citation Index, Cochrane Library and Global Health up to January 2015 for randomised controlled trials that measured effectiveness of ABIs on alcohol consumption. We grouped outcomes into measures of quantity and frequency indices. We used multilevel meta-analysis to estimate pooled effect sizes and tested for the effect of moderators through a multiparameter Wald test. Stratified analysis of a subset of quantity and frequency outcomes was conducted as a sensitivity check.
Results 52 trials were included contributing data on 29 891 individuals. ABIs reduced the quantity of alcohol consumed by 0.15 SDs. While neither the setting nor content appeared to significantly moderate intervention effectiveness, the provider did in some analyses. Interventions delivered by nurses had the most effect in reducing quantity (d=−0.23, 95% CI (−0.33 to −0.13)) but not frequency of alcohol consumption. All content groups had statistically significant mean effects, brief advice was the most effective in reducing quantity consumed (d=−0.20, 95% CI (−0.30 to −0.09)). Effects were maintained in the stratified sensitivity analysis at the first and last assessment time.
Conclusions ABIs play a small but significant role in reducing alcohol consumption. Findings show the positive role of nurses in delivering interventions. The lack of evidence on the impact of content of intervention reinforces advice that services should select the ABI tool that best suits their needs.
Brief interventions on alcohol
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http://dx.doi.org/10.1136/bmjopen-2016-011473
Strengths and limitations of this study
A key strength of this review is the methodologically innovative approach to the meta-analysis through the use of a multilevel meta-analysis.
As a second sensitivity analysis we compared the findings from the multilevel model with a stratified analysis focusing on a subset of outcome variables. Findings from the two analyses were comparable.
Quality assessment criteria were used to assess risk of bias and the majority of studies were at low risk in relation to the randomisation procedure and monitoring of loss to follow-up.
A large proportion of studies did not provide information on other aspects of the study design including blinding of participants to the intervention, intention-to-treat analysis and blinding to outcome measurements.
Our review suggested limited effect for interventions delivered in community settings, but relied on a small number of studies across a wide variety of settings.
Excessive alcohol consumption is a major public health concern, contributing to almost 4% of deaths worldwide,1 ranging from as high as 8% of deaths among men and women in the USA and Norway to 1.4% in the UK.2 ,3 It is estimated that over 10 million people in the UK alone drink more than the recommended daily units.4 Screening to detect individuals drinking alcohol at hazardous or harmful levels and the delivery of a brief intervention on alcohol (ABI) to reduce their consumption have been implemented in primary care settings where their efficacy and effectiveness have been demonstrated.1 The content of ABIs is varied, but usually focuses on the provision of structured advice, involving an assessment of individual risk with feedback and advice, or brief motivational interviewing that takes a more patient-centred approach, or a combination of both.5 Existing systematic reviews have found variability in effect by duration of intervention or number of visits, but this has not taken into account differences in content or provider.6–10 Although there is some emerging evidence that motivational interviewing can be more effective than 'traditional' advice (based on a provider-centred definition of a problem) across a range of health behaviours,11 this is not conclusive.12 Further, while the efficacy and effectiveness of ABIs have been demonstrated in primary care settings,13–15 the evidence base in health settings beyond primary care is weaker with moderate or no effect found in college16 ,17 and community settings.18 Some benefits have been observed from a small number of studies in accident and emergency (A&E) departments,19 ,20 as well as in general hospital settings but among mainly male patients.21 ,22 Implementation research has shown that contextual factors affecting the routine delivery of ABIs in primary healthcare settings are closely linked to practitioners. However, there has been little research looking at the impact of practitioners on intervention effectiveness outside primary healthcare settings.23 ,24
In England, the Government's Alcohol Strategy calls for the increased implementation of ABIs in primary care and A&E settings, while targets for implementing ABIs in these settings as well as antenatal clinics have been set by the National Health Service (NHS) Scotland.25 ,26 The National Institute for Health and Care Excellence (NICE) guidance recommends that ABI should be offered opportunistically by a range of relevant practitioners and front-line staff, while also acknowledging that the strength of evidence was clearer in some health settings compared with others. Nevertheless, this guidance flagged the relevance of social care, criminal justice, community and voluntary sector professionals to supporting alcohol risk-reduction work.27 This recommendation has been implemented by some public health authorities, rolling out interventions in sexual health clinics and community settings such as criminal justice services, and has also been advocated by global health agencies including the WHO.28 Given the international-level, national-level and local-level support for the expansion of ABIs beyond primary care settings, there is an urgent need to understand how a brief intervention process (including setting, provider and content) moderates their effectiveness in order to inform their implementation.5 We therefore undertook a systematic review and metaregression to measure the effect of ABIs on alcohol consumption and how the effect differs by setting, provider group and content of intervention.
Search strategy and selection criteria
We followed the PRISMA guidelines on reporting of systematic reviews.29 Studies eligible for this review were peer-reviewed randomised controlled trials of ABIs published in English. We included all populations aged 16 years or older but excluded populations with complex health problems, for example, studies of people living with HIV, tuberculosis, hepatitis C virus or homeless populations where it is difficult to generalise findings to the general population. Similarly we excluded populations seeking help at specialist addiction centres, mental health services or antenatal clinics. We included studies with control groups comprising: treatment as usual; information-only; assessment only; no assessment; or non-intervention, and excluded control groups consisting of other interventions, including other brief interventions such as advice and extended psychological treatments. Brief interventions were defined as person-to-person discussions on alcohol between one and four sessions and not more than 2 hours total intervention time. Computerised interventions tested alone, group interventions and those that target multiple behaviours were excluded. We also excluded studies where no measure of alcohol consumption was reported.
The primary outcome of interest was a quantitative continuous measure of total alcohol consumption within a specified time frame (standard drinks, grams of ethanol or days of drinking) where the standardised mean difference between brief intervention and control group was measured at the time of follow-up.
We searched: MEDLINE; EMBASE; PsycINFO; CINAHL; Social Science Citation Index and Science Citation Index through Web of Science; Cochrane Effective Practice and Organisation of Care Group specialised register; and Global Health between 1966 and 2015. The search was conducted in January 2015. We also scanned citations and contacted experts in the field to minimise selection bias. The search terms used were: 'Brief intervention' OR 'minimal intervention' OR 'early intervention' OR 'cognitive behavioural' OR 'screening' OR 'counselling' OR 'brief advice' OR 'identification' OR 'managed care' or 'motivational interview' AND 'Alcohol drinking' or 'binge drinking' OR 'alcohol consumption' OR 'alcohol units' OR 'alcohol use and misuse' OR 'alcohol intake' OR 'alcohol rate binge drinking' OR 'beer or wine or lager or spirit drinking' AND 'randomized controlled trial' OR 'random allocation' OR 'double blind methods' OR 'clinical trial' OR 'controlled clinical trial' OR 'multi centre studies'. Searches were tailored to the search functionality of each database (see web appendix).
Supplementary appendices
[bmjopen-2016-011473supp_appendices.pdf]
Eligibility assessment was conducted independently by two reviewers. Disagreements between reviewers were resolved by consensus. We selected a list of risk of bias criteria from recommendations in the Cochrane Collaboration Reviewers' Handbook to assess the quality of the trials.30 Criteria included methods used to generate the allocation sequence to produce comparable groups and concealment of allocation to determine whether intervention allocations could have been foreseen before or during enrolment; blinding of participants and providers to intervention groups; blinding of outcome assessment; incomplete outcome data (including intention-to-treat analysis); and measurement of attrition rate.
Data were extracted from each publication into a database piloted on five studies, independently by GJM-T, LP, AO and JB without blinding authors' names, study site, intervention or trial results. These researchers jointly reviewed the extracted data and 10% of studies were double extracted. Data were extracted on characteristics of trial participants, type of interventions (including content, duration, frequency, provider, setting), type of outcome measure, time of assessment and effect estimates.
We extracted continuous outcomes in the units in which they were presented and then converted them into Cohen's d for comparability. When extracting continuous outcomes, we preferred estimates that were analysis of covariance adjusted for baseline score, followed by unadjusted post-test scores and finally repeated measures or 'change score' models. Change score models were reparametrised into a raw score metric using r=0.5, with sensitivity analysis at r=0.1 and r=0.9. Though past reviews have attempted to convert all measures to 'natural units' such as grams of ethanol, we decided that this was inadvisable because of the large number of trials in this review and because of our goal to include all relevant information, a key benefit of multilevel meta-analysis models.
We grouped intervention content into three categories (figure 1). The first was motivational interviewing, including motivational interviewing-style, advice approaches such as FRAMES, motivational enhancement therapy as adapted for Project MATCH (Project MATCH Research Group, 1998) or brief motivational interviewing. We also identified a second subset of trials that tested specific enhanced interventional protocols for motivational interviewing (eg, drink less) or additions to motivational interviewing (eg, cognitive–behavioural approaches) from other therapeutic modalities and labelled this category motivational interviewing 'plus' (MI plus). A third subset included brief advice approaches, often labelled as such without any additional information.
Categories and definitions of interventions by content, provider and setting.
Intervention providers were grouped into: counsellors (defined as any mental health providers including clinical and research psychologists or clinical social workers); general practitioners (including primary care providers and general physicians); nurses (including research or clinical nurses on secondment); peer-delivered and different providers (but with no fixed provider). Setting of intervention delivery was categorised as: A&E services; community-based delivery that included a range of non-clinical settings; primary or ambulatory care delivered in clinical settings as outpatient services; hospital inpatient services and university services.
The systematic review protocol was registered on PROSPERO at the University of York (CRD42014014799).
We grouped outcomes hierarchically. We identified an overarching set of outcomes addressing quantity of alcohol consumption, from which we created two subsets of outcomes: (1) amount of alcohol consumed per unit of time; and (2) amount of alcohol consumed per drinking occasion. We also identified an overarching set of outcomes addressing frequency of alcohol consumption, from which we created a subset of outcomes including (1) frequency of any drinking occasion; and (2) frequency of binge drinking occasions.
For each overarching set and subset of outcomes, we specified five models: (1) an unconditional model that included all eligible continuous outcomes; (2) a model that included a grand mean-centred covariate for time of follow-up postbaseline, to address differences in follow-up; (3) a model including where the intervention was initially delivered and time of follow-up; (4) a model including the provider of the intervention and time of follow-up; and (5) a model including the content of the intervention and time of follow-up. To estimate mean effects for all groups simultaneously, we refit models with no intercept.31 We used the statistical package metafor,32 which implements advanced meta-analysis models, in the R environment for all multilevel analyses.
For our main analysis, we used a multilevel meta-analysis method to estimate the pooled effect sizes.33 Models included random effects on the effect size and study levels because of anticipated heterogeneity both within and across studies. Several trials tested different intervention or provider types in the same experiment, but insufficient trials did this to treat intervention as a 'within-trial' covariate. In order to adequately model these two moderators, we split the control groups in two for these trials and treated each intervention–control comparison as a separate trial. This avoided double-counting participants across intervention–control comparisons. Moreover, several studies presented results stratified by group. In our multilevel meta-analyses, we included these in the same cluster. We tested for the effect of our hypothesised moderators by conducting a multiparameter Wald test on provider, setting or content coefficients as appropriate. We additionally examined the residual heterogeneity, measured as I2, between the time-adjusted model and the models including each of the three sets of covariates. We regarded a p<0.05 as statistically significant and a p<0.10 as marginal, but not significant.
Sensitivity check
In addition to sensitivity analysis on the correlation used for repeated measures conversion, we estimated a set of metaregressions for each subset of outcomes including one effect size per relevant comparison for each of first and last follow-up in the included trials. We did this by combining intervention and control groups where appropriate, and by selecting effect sizes within studies that used shorter time periods for measurement and timeline follow-back procedures over general frequency/quantity questionnaires. We also treated non-overlapping subgroups from the same study as separate data points as suggested by Borenstein et al.34 Sensitivity analyses were estimated in Stata V.13.1 (Stata Corp 2013) and R (R Core Team. A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2016). We did not undertake meta-analysis of effect sizes from common time points because these models would have been poorly powered.
We identified a total of 4551 records from the search of electronic databases and 41 records from key experts. A total of 52 studies met our inclusion criteria, with three studies presenting different outcomes for the same data and therefore considered as one.35–37 One study was dropped as it only contained biological outcomes which were not included in the main analyses.38 The review and selection process is summarised in figure 2.
Flow chart of systematic review and study selection. ABI, brief interventions for alcohol; RCT, randomised controlled trial.
Included studies contributed data for 29 891 individuals. Table 1 presents a summary of study characteristics (country, age, sex and sample size) as well as type of intervention (setting, provider and content), key outcomes and time of assessment. Most studies originated from Europe or North America with the exception of three studies from Australia, Taiwan and Thailand.72 ,76 ,77 Almost half (45%) of the studies were conducted in the USA and 22% in the UK.
Characteristics of included studies
In total, 68% of trials were delivered in primary or healthcare settings (hospital or A&E). Only six studies were conducted in community settings defined as: military;55 ,61 ,62 research sites recruiting a sample through a household survey;64 and women at risk of alcohol-exposed pregnancy (defined as aged 18–44 years, with ineffective or no use of contraceptives, sexually active in the past 6 months, but not currently pregnant or planning a pregnancy) recruited via the media, in a prison, community health centre and a gynaecology centre;67 and one criminal justice setting.87 The most common providers included counsellors, who were the sole providers of interventions in 43% of trials, and physicians who accounted for 24% of trials. A minority category of different providers (8%) included a combination of psychologists, social workers or research nurses. Intervention categories were well distributed, though a majority of trials (47%) included motivational interviewing alone and 39% included MI 'plus'. A total of 50 trials reported 275 eligible effect sizes on outcomes measuring quantity of alcohol consumed with a mean follow-up of 9 months. This is summarised in table 2.
Summary of study characteristics
The majority (71%) of studies were categorised as low risk of bias in relation to randomisation and allocation concealment strategies. In the majority of studies, the process used to assess blinding of participants and providers as well as outcome assessment was unclear. Intention-to-treat analysis was conducted in 47% of studies and loss to follow-up assessed in the majority (80%) of studies. This is summarised in table 3 and risk of bias assessment for all trials is included in the online web appendix table 1.
Summary risk of bias assessment
Metaregression on combined quantity and frequency outcomes
Interventions produced a beneficial effect at reducing the quantity of alcohol consumed by 0.15 SDs—a small but statistically significant effect (see table 4). This effect persisted after controlling for time to follow-up and when examining the subset of outcomes. In unconditional models and models controlling for time of follow-up, study-level heterogeneity as measured by I2 (ie, the percentage of variation between effect sizes due to heterogeneity rather than chance) was in the small-to-moderate range (0–40%) as defined by the Cochrane Handbook.30 Findings were robust to sensitivity analysis on the pre-post correlation in change score models. The mean time-adjusted effect of brief alcohol interventions on frequency of alcohol consumption outcomes was similar in magnitude (d=−0.15, 95% CI (−0.20 to −0.11)), but lower in heterogeneity (I2=23%), compared with the effect on the quantity of alcohol consumption (table 5). The time-adjusted effect remained statistically significant when limited to the subset of outcomes (frequency of drinking occasions d=−0.12, 95% CI (−0.19 to −0.06) and frequency of binge drinking d=−0.17, 95% CI (−0.23 to −0.11)).
Results of multilevel metaregression for quantity outcomes
Results of multilevel metaregression for frequency outcomes
For all quantity outcomes the setting of intervention did not appear to fully explain heterogeneity between studies, with residual heterogeneity at 34% and a statistically marginal but non-significant joint test of moderators (p=0.09). Interventions conducted in university settings (d=−0.20, 95% CI (−0.39 to −0.09)) and in primary or ambulatory care (−0.20 to (−0.27 to −0.13)) appeared to be most effective, with a small but statistically significant effect of the intervention. Interventions delivered in community settings (military, criminal justice, research sites and targeted recruitment) did not appear to be effective (−0.03 (−0.16 to 0.10); table 4).
For all frequency outcomes, the setting of intervention did not explain heterogeneity (residual I2=25%, Wald p=0.54). Of subgroups with statistically significant pooled effect sizes, interventions delivered in university contexts appeared to be most effective for frequency outcomes (−0.21, (−0.33 to −0.08)). Analysis was hampered by the small numbers of studies in several categories (table 5).
When limiting the analysis to the subset of either quantity or frequency outcomes the setting of intervention did not explain heterogeneity (all joint tests of moderators p>0.10).
In the model including all quantity outcomes, the provider of intervention did not meaningfully explain heterogeneity, based on I2 for this model (34%). Interventions delivered at least in part by nurses appeared to have the largest effect by magnitude (d=−0.23, 95% CI (−0.33 to −0.13)), though this difference was not supported by a significant joint test of moderators (Wald p=0.09).
Analyses with more specific sets of outcomes revealed a similar picture. Examination of effects at the first time point for the amount of alcohol per unit time showed that interventions delivered at least in part by the nurses (d=−0.30, 95% CI (−0.47 to −0.12)) were the most effective, with a significant joint test of moderators (Wald p=0.048; see online web appendix table 2). Interventions delivered by a range of different providers were least effective and did not yield a statistically significant effect. However, few studies were included in this category of providers. The provider of intervention explained some heterogeneity when the analysis was limited to the amount of alcohol per unit time (residual I2=32%, Wald p=0.01) but not per drinking occasion.
For frequency outcomes, the provider of intervention did not explain heterogeneity either combined (Wald p=0.17) or for drinking occasion per unit time (Wald p=0.73) but the effect was marginal, but non-significant, for bingeing occasions (Wald p=0.07).
For quantity outcomes, the content of intervention did not explain a statistically significant amount of heterogeneity (residual I2=39%, Wald p=0.54), with little apparent reduction in I2. While all content groups had statistically significant mean effects, brief advice appeared to be most effective (d=−0.20, 95% CI (−0.30 to −0.09)) with the impact of motivational interviewing (d=−0.13) and MI plus (d=−0.16) also statistically significant.
For frequency outcomes, the content of intervention did not explain a significant amount of heterogeneity (residual I2=29%, Wald p=0.48). Effects by the content group for motivational interviewing were similar to those in the analysis of quantity outcomes, though brief advice did not have a statistically significant effect on the frequency of alcohol use (−0.08 (−0.26 to 0.09)).
Estimates of heterogeneity remained the same when limiting the analysis to the subset of either quantity or frequency outcomes.
Sensitivity check: metaregression on subset of outcomes by first and last time point
Overall effect estimates based on first and last time point were similar to the corresponding value reported in the main analysis, but estimates of heterogeneity (measured through I2) tend to be higher. Setting of intervention explained some heterogeneity for the alcohol per unit time outcome at the first time of marginal significance (residual I2=49%, Wald p=0.08). Findings also suggest that the provider explained some heterogeneity (residual I2=43%, Wald p=0.05) with nurses having the biggest effect (d=−30, 95% CI (−0.41 to −0.20)) and interventions delivered by different providers had the least effect (d=-0.07, 95% CI (−0.12 to −0.03)). The content of intervention explained some heterogeneity (residual I2=43%, Wald p=0.04), brief advice was the most effective (d=-0.25, 95% CI (−0.42 to −0.07)) and motivational interviewing was least effective (d=-0.09, 95% CI (−0.15 to −0.04); figures 3⇓–5). With the exception of content, evidence of heterogeneity did not remain significant at the last time point. There was no evidence of heterogeneity for alcohol consumed per drinking occasion or for either subset of frequency outcomes. All findings are summarised in the online web appendix tables 2–5.
Metaregression analysis on alcohol consumed per unit time at first follow-up by setting of intervention. A&E, accident and emergency.
Metaregression analysis on alcohol consumed per unit time at first follow-up by provider of intervention.
Figures 5
Metaregression analysis on alcohol consumed per unit time at first follow-up by content of intervention.
Our findings provide important new evidence on how the effectiveness of brief alcohol interventions differs by setting, provider and content, informing us of optimum modality. Our findings show that the provider of intervention may matter. We observed some reductions in heterogeneity in the multilevel analysis of amount of alcohol consumed per unit time, and interventions delivered by nurses having the most effect in reducing the quantity of alcohol consumed, but not the frequency of consumption. This finding builds on other evidence showing a modest effect of brief interventions delivered by non-physicians (nurses and healthcare workers) in primary care settings.24 We found that neither setting nor the content appeared to significantly moderate intervention effectiveness: we found little evidence on the effectiveness of brief interventions in community settings or A&E ; brief advice was the most effective content in reducing the quantity of alcohol consumed but not the frequency of drinking and there seemed to be little difference in the effect of MI or MI plus on either the quantity or frequency outcomes.
While the setting did not explain heterogeneity, findings show that university and ambulatory/primary care settings were the most effective in terms of magnitude of effect size, which is supported by previous reviews in this field.14 ,15 ,17 Prior research has suggested that while ABIs delivered in A&E settings may be effective in reducing alcohol consumption among hazardous and harmful drinkers,19 it may not provide the most appropriate context for discussion on alcohol use.88 The brevity of visits, lack of privacy for the delivery of the intervention and severity of injury may hinder the interaction between the patient and the practitioner reducing effectiveness.88–91 Other evidence shows that discussion of drinking behaviours is facilitated by a good relationship between the practitioner and the client.73 Our finding of increased reduction in alcohol consumption when the intervention is delivered by a nurse is important. The majority of previous research has focused on physician-led interventions, but there is growing evidence to support the effectiveness of nurse-led interventions in primary care and other settings.24 ,92 ,93 As the largest group of healthcare workers with repeated patient contact and with a health promotion remit as part of their role, they are well placed to deliver ABIs.92 ,94 Barriers to nurses delivering the interventions include lack of time, worry about losing trust of the patient and inadequate training.95 ,96 Resources and training should be provided to support nurses to undertake this role and embed it within services. The provision of ABIs under the category of different providers was not associated with a reduction in the consumption in alcohol. This may be related to problems with training of different providers, but the category was small and included a diverse range of providers, making the finding difficult to interpret. Similarly only a moderate effect was associated with counsellors, but again this definition encompasses a diverse group of practitioners ranging from clinical psychology students75 to alcohol workers with specialist training in alcohol counselling.56
While our categories of intervention content did not meaningfully or statistically explain heterogeneity in either quantity or frequency outcomes in the multilevel analysis, they did in the stratified analysis for first and last assessment time points. Effect sizes for quantity outcomes for all three classes of content were statistically significant, with brief advice yielding the largest effect. This provides important empirical evidence that brief advice can reduce alcohol intake, where evidence was lacking, and corroborates previous research that demonstrated no difference in effect between brief advice and longer motivational interviewing in reducing the harmful levels of drinking in A&E, primary care and criminal justice settings.12 ,56 ,97 ,98
A key strength of this review is the use of a multilevel meta-analysis method to integrate all the relevant effect sizes from the included studies. This circumvented problems in other systematic reviews around the selection of specific effect sizes for meta-analysis. However, we were unable to explicitly model correlation between outcomes within studies, though simulation evidence suggests that this may not have a large impact on the estimation of intervention effects.99 We used Cohen's d to standardise outcomes. While this is common across many systematic reviews addressing continuous outcomes, it is uncommon for systematic reviews of alcohol outcomes, where standardisation is often in terms of standard drinks or grams of ethanol consumed. This may somewhat limit comparability between reviews, but it was a critical step in employing the multilevel meta-analysis model we used. As a second sensitivity analysis, we compared the findings from the multilevel model with a stratified analysis focusing on a subset of outcome variables. Findings from the two analyses were comparable. The stratified analysis of quantity of alcohol consumed per unit time suggested stronger effects of setting, provider and content of intervention at the first time point of assessment than indicated in the multilevel models but with comparable effect estimates within each category. Tests for publication bias do not yet exist for multilevel meta-analyses. While our tests using all available effect sizes did not reveal significant publication bias on either the quantity or frequency outcomes, it is unlikely that this is the best way to test publication bias in the context of dependent effect sizes. While we used the broadest categories appropriate for setting and provider of interventions, the number of studies included in the meta-analysis examining frequency outcomes meant that metaregressions were likely underpowered. We did not examine the effect of sex, ethnicity or age as a covariate since the sample size would have been too small to conduct a multivariate metaregression analysis. As the number of trials grows, this meta-analysis should be repeated in order to better estimate the differences between categories and examine the effect of other factors.
These findings should also be viewed in the context of study-level heterogeneity. In our multilevel meta-analyses, heterogeneity was surprisingly low considering the diversity of settings, providers and modalities included in this body of evidence. One possible reason for this is that because we included all relevant outcomes, we avoided some of the 'random errors' that may arise when only selecting one outcome per study. That is, including more information from each study will provide an estimate of statistical heterogeneity that more meaningfully accounts for study-level differences. This is not to say that it was inappropriate to explore this heterogeneity through structured and prehypothesised subgroup analyses, as was done here. Rather, the magnitude of difference in effects between studies may not be as pronounced as would be expected in a systematic review with such diverse interventions. While there was a low risk of bias in relation to some aspects of the study design (randomisation, loss to follow-up), there was a high percentage of unclear risk for many criteria, limiting our ability to fully assess the risk of bias. Because of the substantial number of categories for many of our metaregressions, we were unable to conduct a sensitivity analysis on risk of bias as that would have resulted in underpowered models.
Further research is needed to examine the effectiveness of ABIs in community settings. Our review suggested limited effect but relied on a small number of studies across a wide variety of settings. Our review excluded the use of computer-based interventions, which may be an important approach to reaching populations who do not consider themselves at risk. Some evidence shows that computer-delivered interventions with personalised feedback can effectively reduce alcohol consumption at short-term and long-term follow-up; however, the evidence is weaker when comparing direct feedback between face-to-face and computerised feedback.85 Our findings clearly show the importance of provider in effective delivery of ABIs and it will be important for future research to measure effectiveness of computerised feedback against different providers. Subsequent trials should also comprehensively describe intervention components to enable finer-grained analysis of the relationship between specific aspects of intervention modalities and their effectiveness.
Findings of this review contribute significantly to the understanding of the key processes involved in the delivery of effective ABIs, and have important policy implications for the design of preventative alcohol strategies both in the UK and internationally. The review provides important new evidence on the effectiveness of brief advice in reducing quantity of alcohol consumed and the role that nurses play in moderating the effectiveness of interventions. Resources should be prioritised to provide further support and training for nurses to deliver ABIs, as well as to undertake research to understand why nurse-led interventions are more effective so that appropriate training can be provided to other practitioners.
The authors would like to acknowledge Antonio Gasparinni and Colin Muirhead who provided statistical advice on the multilevel meta-analysis and sensitivity check applied in the review.
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Twitter Follow Dorothy Newbury-Birch at @dotbirch
Contributors LP and CA developed the study protocol with advice from EK. LP conducted the search with assistance from DN-B. LP and DN-B checked the eligibility criteria of all manuscripts with help from AO. AO and JB conducted the data extraction and validation of extraction. GJM-T developed the statistical approach and conducted all statistical analyses in collaboration with LP. All authors commented on the manuscript.
Funding The study was funded by Camden and Islington Public Health, who commented on the study protocol, analysis and interpretation of findings.
Data sharing statement No additional data are available.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/


Julia Roberts Celebrates Twins Hazel and Phinnaeus Turning 17 With Adorable Throwback Pic
By Mona Khalifeh 5:26 PM PST, November 28, 2021
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Julia Roberts is celebrating the birth of her and husband Danny Moder's twins, Hazel and Phinnaeus Moder. The 54-year-old actress took to Instagram on Sunday to share an adorable throwback of her children in honor of their 17th birthday.
"Seventeen of the Sweetest years of life ✨ 👫♥🥳. 🎂🎂🎂🎂🎂🎂🎂🎂🎂🎂🎂🎂🎂🎂🎂🎂🎂," Julia wrote next to the photos of her and her then-babies.
The post was met with several comments from fans and celebrities alike, including Julia's niece and new mom, Emma Roberts, who commented on the sweet snap, leaving behind a set of red heart emojis.
A post shared by Julia Roberts (@juliaroberts)
Danny shared a throwback of his own, thanking the twins for helping him through fatherhood.
"These rabble rousers… 17 today. thank you for helping me through fatherhood," the 52-year-old cinematographer wrote.
A post shared by modermoder (@modermoder)
In July, their daughter, Hazel, made her red carpet debut. The then-16-year-old attended the premiere of Flag Day during the 74th Cannes Film Festival in Cannes, France, looking lovely as she posed on the red carpet alongside her father. Julia and Danny are also parents to 14-year-old son Henry.
At Cannes, Hazel went '90s chic in a butterscotch yellow button-up lace shirtdress with black Mary Janes, while Danny sported a classic black tuxedo to promote his cinematography work on Flag Day, a film featuring Katheryn Winnick, Sean Penn, Regina King, and Josh Brolin.
P. Lehman/Barcroft Media via Getty Images
Back in 2018, Julia opened up about her 19-year marriage and her family on an episode of the Goop podcast, and shared how happy she is that she married Danny and started a life with him.
"It just gets deeper, it just gets more complex," Julia said of her marriage. "You're young and you fall in love and go, 'Oh, yeah, we're going to get married and we're going to build a house and will have kids,' and all these things that we all kind of dream of, but you don't know if you're going to like the same couch, and you don't know if he is going to want to get, like, patterned towels. Then, of course, the bigger ones are, will you parent in a way that has balance to it, that holds hands in philosophy? You just don't know these things until you are right there doing it, and we are so fortunate that there is some kind of inexplicable harmony to the way we do things, because we do things differently .... but there's something together that makes all the sense in the world."
Julia added, "The best decision I ever made in my entire life was to hitch my wagon to Danny Moder."
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Government Departments
Abu Dhabi Vocational Education and Training Institute (ADVETI) (Mohammed Bin Zayed City)
Abu Dhabi Vocational Education and Training Institute (ADVETI)
95005 Abu Dhabi
Al Jazirah Institute of Science and Technology Building, 51st Street ( Abu Dhabi ) Directions on Google Map
Mohammed Bin Zayed City
Near Abu Dhabi Polytechnic
adveti.ac.ae
https://www.instagram.com/adveti_abudhabi/
https://www.linkedin.com/school/abu-dhabi-vocational-education-and-training-institute-adveti-/
https://twitter.com/adveti_abudhabi?lang=en
https://www.youtube.com/channel/UCjWauwvRyvrGIfL1D_EoJNg
Other Government Departments in Abu Dhabi
Masdar City, Abu Dhabi
General Authority of Islamic Affairs & Endowment (GAIAE)
Abu Dhabi City, Abu Dhabi
Abu Dhabi Sports Council (ADSC)
Al Khalidiyah, Abu Dhabi
Emirates Authority for Standardization & Metrology (ESMA)
Abu Dhabi Ports Company (ADPC)
Al Mina, Abu Dhabi
Statistics Centre - Abu Dhabi (SCAD)
Bain Al Jessrain, Abu Dhabi
Abu Dhabi National Exhibitions Company (ADNEC)
Madinat Zayed, Abu Dhabi
Securities and Commodities Authority (SCA)
National Media Council (NMC)
Government Departments85


Garmin suffers global outage after suspected ransomware attack
by Iain Treloar
Fitness tracking titan Garmin has been affected by a wide-ranging global outage which has shut down the company's website, disrupted production lines and prevents users from uploading activities.
In a statement posted on Garmin and Garmin Connect, the company said that "We are currently experiencing an outage that affects Garmin.com and Garmin Connect. This outage also affects our call centers, and we are currently unable to receive any calls, emails or online chats. We are working to resolve this issue as quickly as possible and apologize for this inconvenience."
The outage presented at around 3am Thursday (UTC) – approaching 24 hours ago – and there is as yet no indication from Garmin as to when normal service will resume. The company has delivered a notification to some users that they "will be performing system maintenance at 5pm [UTC, Friday] lasting approximately four hours", taking the outage time well into a second day.
ZDNet reports that Garmin staffers have claimed on social media that the company was the victim of a ransomware attack, where malicious hackers encrypt a company's data and hold it hostage until a ransom has been paid, usually in bitcoin. Canyon was also the victim of a similar attack early this year.
Garmin has not provided formal confirmation of this having taken place, referring to the issue more nebulously as an "outage" or "maintenance". However, Taiwanese tech website ITHome reports that the company's manufacturing facilities in Taiwan will be down for two full days of work, with internal memos referring to a "virus", without naming ransomware specifically.
There are unconfirmed reports that the strain of ransomware used is EvilCorp's WastedLocker, which primarily targets US-based corporations. Security companies believe that the group is based in Russia.
There are a number of concerning implications for Garmin users beyond the fact that activities in this time can't be synced to Strava (and as such, didn't happen). The company sells hiking trackers and provides equipment for the automotive and aviation industries – places that you really don't want things to go wrong – and holds sensitive data of its millions of users.
CyclingTips has contacted Garmin for comment, but as yet has received no response.
In the meantime, Garmin-using cyclists can save ride data manually by USB – just browse to your activities directory, save the relevant .fit or .gpx file to your desktop, and upload it from there to your preferred activity tracking service.
#Garmin
Canyon bicycles hit by cyber attack
Exercise app accused of "massive data leak"


Encyclopedia > September 11, 2001 Terrorist Attack Responsibility
September 11, 2001 Terrorist Attack/Responsibility
There were reports that the Palestinian group DFLP (Democratic Front for the Liberation of Palestine) took responsibility for the crashes, but this was denied by a senior officer of the group soon after. While there are filmed reports of celebrations on the West Bank, but according articles in the German magazine Stern and the Swedish daily newspaper Dagens Nyheter[?] at least one of them was staged. Palestinian leader Yasser Arafat denounced the attacks, saying it was counterproductive to any peace between Israelis and Palestinians.
Next in line to claim responsibility were the Taliban of Afghanistan. The Taliban government subsequently denounced the attack and claimed that it was not connected to Osama Bin Laden, the terrorist living in Afghanistan who the U.S. government declared the prime suspect.
Although there is no explicit evidence linking Bin Ladin's Al-Qaida organization (or, indeed, any other group) to the crime, intelligence experts speak of a "short list" of prime suspects -- groups that possess both the means and the motive to carry out the crime. It appears certain that all hijackers have Arabic origins, and none are Afghani; moreover, both in their immense scale, careful planning and refraining from claiming responsibility, the attacks are reminiscent of Al-Qaida's previous attacks.
Virtually all world leaders, including traditional enemies of the United States such as Libyan president Qadhafi, Palestinian leader Arafat, Iranian president Khatami[?] and the Afghanistan Taliban government, denounced the attacks and expressed sympathy for the American people. An exception is Saddam Hussein, the ruler of Iraq who called the attacks the fruits of U.S. crimes against humanity.
Various Arab- and Muslim-world news sources carried opinion pieces and articles that pointed to some form of Zionist conspiracy to frame the Arab world to the benefit of Israel. It is interesting to note that in a Gallup[?] survey of 10,000 inhabitants of sample countries with a Muslim majority, only 18% believed that the Arabs responsible.
Worldwide, a significant minority see the attack as an outcome of past United States involvement in the Middle East and surrounding area, and fear that a violent response will only continue the cycle. The majority worldwide viewpoint is that such acts of terrorism are only to be expected given the economic and cultural imperialism of the United States and the multinational corporations which are identified with it. The creation of pockets of hatred, according to this viewpoint, is an inevitable consequence of the overwhelming outside economic pressure placed on poor countries with minimal control of their political destiny. Notwithstanding this, the majority of people in most nations also believe that terrorism is an absolute evil, that cause does not equal justification.
September 11, 2001 Terrorist Attack - Full Timeline
In Memoriam - Casualties - Missing Persons - Survivors - Personal experiences
Donations - Assistance - Closings and Cancellations - Memorials and Services
US Governmental Response - Responsibility - Hijackers - Political effects - Economic effects
See also: "War on Terrorism" -- U.S. invasion of Afghanistan -- 2001 anthrax attack -- World Trade Center -- The Pentagon -- New York City -- Washington, D.C. -- AA Flight 11 -- UA Flight 75 -- AA Flight 77 -- UA Flight 93 -- U.S. Department of Defense -- terrorism -- domestic terrorism -- Osama bin Laden -- Taliban -- Islamism -- Afghanistan -- collective trauma -- September 11
External Links & References
Official document containing information from intelligence and criminal investigation as released by the British PM Tony Blair on his official webside, Oct. 4, 2001: Responsibility for the terrorist atrocities in the United States, 11 September 2001. See:
http://www.pm.gov.uk/
http://news.independent.co.uk/uk/politics/story.jsp?story=97692
http://news.bbc.co.uk/
THE INVESTIGATION: Fugitive on F.B.I. List Arrested Outside Chicago (http://archive.nytimes.com/2001/09/20/national/20CND-WASH), New York Times, 9/20/2001]
Millions of shares sold before disaster (http://www.thetimes.co.uk/article/0,,2001320007-2001323297,00.htm), The Times, 9/18/2001
For a non-Islamic perspective unreservedly justifying the attacks, see Indian communist revolutionary Vaskar Nandy's article in the Oct 27, 2001 issue of Economic and Political Weekly, Bombay, India.([[1] (http://www.epw.org.in/showArticles.php?root=2001&leaf=10&filename=3635&filetype=html)])
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Posted on December 1, 2018 by Evan Gough
A New Atomic Clock has been Built that Would be off by Less than a Second Since the Big Bang
Physicists have developed an atomic clock so accurate that it would be off by less than a single second in 14 billion years. That kind of accuracy and precision makes it more than just a timepiece. It's a powerful scientific instrument that could measure gravitational waves, take the measure of the Earth's gravitational shape, and maybe even detect dark matter.
How did they do it?
The "Royal Flush" of Clock Performance
Physicists at the National Institute of Standards and Technology say their new atomic clock is based on the rare-earth element ytterbium. They use a grid of laser beams called an optical lattice to trap 1000 ytterbium atoms. The atoms naturally "tick" by switching between two energy levels. That action is called atomic electron transition, and it takes nanoseconds to occur. Each time they tick, or change energy levels, the electrons emit microwave energy, which can be detected. The NIST physicists built two of these ytterbium clocks, and by comparing them, they have achieved record-breaking performance.
This record-breaking performance is measured in three ways:
Systematic uncertainty: This is how well the clock represents the natural vibrations of the ytterbium atoms. The ytterbium clock was off by only one billionth of one billionth.
Stability: This is how much the frequency of the clock changes in a specified time. In this case, they measured their ytterbium clock and it changed by only 0.00000000000000000032) over a day.
Reproducibility: This measures how closely two ytterbium clocks tick at the same frequency. In 10 comparisons between the pair of clocks, the difference was again less than one billionth of a billionth.
"Systematic uncertainty, stability, and reproducibility can be considered the 'royal flush' of performance for these clocks," project leader Andrew Ludlow said in a press release. "The agreement of the two clocks at this unprecedented level, which we call reproducibility, is perhaps the single most important result, because it essentially requires and substantiates the other two results."
Atomic clocks have been in use for decades. This image shows banks of atomic clocks at the US Naval Observatory, used to define the time standard for the US Dept. of Defense. Image: By US Naval Observatory – http://tycho.usno.navy.mil/gif/clockvaults.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=5538835
Clocks, Gravity, and Relativity
Einstein showed us that time passes differently depending on the gravity you're subject too. The ticking of the atoms in an atomic clock is slowed down when observed in stronger gravity. On the top of Mt. Everest, for example, time moves more quickly than at the bottom of the Mariana Trench. That's because, here on Earth, the force of gravity is concentrated at the center of the planet. The further you are away from the center, the less gravity there is. The effect is not great, perhaps only millionths of a second. But it's there. That seems counter-intuitive somehow, but that's what Einstein showed, and he's been proven correct.
The exceptional thing about this new atomic clock is that it's demonstrated reproducibility means the clock's error is below our ability to detect the gravitational effect on time here on Earth.
Physicists at the National Institute of Standards and Technology (NIST) have developed an atomic clock based on the element ytterbium that has broken performance benchmarks for atomic clocks. Physicist Andrew Ludlow pictured. Image Credit: Burrus/NIST
NIST physicist Andrew Ludlow explains it like this: "… the demonstrated reproducibility shows that the clocks' total error drops below our general ability to account for gravity's effect on time here on Earth. Hence, as we envision clocks like these being used around the country or world, their relative performance would be, for the first time, limited by Earth's gravitational effects."
The physicists say that now that we have a clock that's accuracy is greater than the gravitational effect on time, we can use the clock to measure Earth's gravitational shape. The usual way of measuring the Earth's gravitational shape is by measuring its tides. Tidal gauges placed around the world are used, but their accuracy is only with several centimeters. The new clocks could bring that accuracy down to less than a single centimeter.
In fact, these ytterbium clocks can be used to measure much more than Earth's gravitational shape. They can be used to measure space-time itself, and to detect gravitational waves from the early universe. It's possible that they could even measure dark matter. At this level of accuracy and precision, this instrument is much more than just a clock.
A Portable, Game-Changing Atomic Clock
It's not only gravity that can effect a clock like the ytterbium clock. Other environmental effects can disrupt the device's accuracy. They must be kept cooled and they must be isolated from any stray electrical fields. The new clocks are shielded from electrical and heat effects so that they can be accounted and corrected for.
With improvements like electrical and thermal shielding, the physicists are building portable ytterbium clocks that can be transported to different labs to measure and compare other clocks. They could also be moved to other locations to study relativistic geodesy techniques. This would be a game-changer, because currently, our best atomic clocks are room-sized, so-called "fountain-clocks" which use the caesium atom to define the second.
But that could all be about to change with the new clocks.
Goodbye Caesium, Hello Ytterbium
Previous atomic clocks are based on the element caesium, which up to now provided the most accurate timekeeping available. The vibration of the caesium atom has been used since the 1960s to define the duration of a single second in the International System of Units (ISU). But with the development of the ytterbium clock, caesium's time might be up.
The first caesium clock was built in 1955, and since then it's been the gold standard. The official definition of the second, if you're interested, has been in use since 1967. It says: "The second is the duration of 9 192 631 770 periods of the radiation corresponding to the transition between the two hyperfine levels of the ground state of the caesium 133 atom." Then in 1997 they clarified it to mean the caesium had to be at 0 Kelvin.
The world's first caesium atomic clock was built at the UK National Physical Laboratory in 1955. Since then, it has been used to define the length of a second. Image: By National Physical Laboratory – http://www.npl.co.uk/upload/img/essen-experiment_1.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=5543813
Other atomic clocks have been built using rubidium, which can be made portable. They're not as accurate as caesium, but they're good enough for applications like GPS, mobile phone base stations, and for controlling the frequency of television stations. But with the development of the new atomic clock using the ytterbium atom, we may have the best of both worlds: unprecedented scientific accuracy, and portability.
The new ytterbium atomic clock is a leading candidate to re-define the definition of how ling one second is. That's because it meets the accuracy threshold defined by the International System of Units. That body said that any new definition would require a 100-fold improvement in validated accuracy over the cesium clocks currently used to define the second.
We used to define time by the rotation of the Earth, but we've come a long way since then. An atomic clock using the tick-rate of a rare-earth element to measure the gravitational shape of the Earth, gravitational waves from the early Universe, and maybe even dark matter is something no historical human could have ever imaged when they stuck a stick in the ground to make a sun dial.
Press Release: NIST Atomic Clocks Now Keep Time Well Enough to Improve Models of Earth
Research Paper: Atomic clock performance beyond the geodetic limit
MIT News: Atomic timekeeping, on the go
Wikipedia: Atomic clock
Wikipedia: Caesium standard
Wikipedia: Atomic electron transition
CategoriesPhysics, Science, Technology Tagsatomic clock, caesium, cesium, NIST, second, ytterbium, ytterbium clock
2 Replies to "A New Atomic Clock has been Built that Would be off by Less than a Second Since the Big Bang"
Pvt.Pantzov says:
Larry Beckham says:
"The new clocks could bring that accuracy down to less than a single centimeter." A SINGLE CENTIMETER! That is amazing!!!
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ART SONG RECITAL Paloma Bruce (soprano) with Catherine Norton (piano)
Wed Jun 29th 2011, 12:15–1:00 pm ◀ This event has finished
Schubert: Nähe des Geliebten, op. 5 no. 2, D. 162
Schubert: Suleika I, op. 14 no. 1, D. 720
Schubert: Rastlose Liebe, op. 5 no. 1, D. 138
Schubert: Seligkeit, D. 433
Granados: El majo discreto (from Colección de tonadillas)
De Falla: Siete canciones populares españolas
1. El Paño Moruno
2. Seguidilla Murciana
3. Asturiana
4. Jota
5. Nana
6. Canción
7. Polo
Harris: Wild Daisies (from Wild Daisies)
The Swans
Moore: Dearest Mama (from The Ballad of Baby Doe)
Barber: Sure on this Shining Night op. 13 no. 3
Paloma Bruce
Paloma Bruce is a lyric coloratura Soprano from New Zealand who is now based in London. She was an PWC Dame Malvina Major Emerging Artist with NZ Opera in 2005. She graduated from Victoria University of Wellington with a Bachelor of Music (first class honours). Paloma is currently on a UK tour with The Merry Opera company playing the roles of 'Philcomnia/Leona/Partheonis' (alt.) in Offenbach's 'La Belle Hélène (Troy Boy)'. Paloma recently performed in Swansea City Opera's 3-day masterclass with David Syrus (Head of Music ROH) where she performed in scenes from 'Die Entführung aus dem Serail' (Konstanze) and Bizet's 'Carmen' (Frasquita). Later this year she will be creating the role of 'Julia Bertram' in the world premiere of Jonathan Dove's 'Mansfield Park' and playing the role of 'Frasquita' in Bizet's 'Carmen' with Heritage Opera.
Catherine Norton
Catherine Norton is a pianist from New Zealand who studied with Dr Thomas Hecht at Victoria University of Wellington, winning the VUW Concerto Competition in 2002. She soon became sought after as an accompanist specialising in vocal repertoire, and in 2006 was an Emerging Artist with the NBR New Zealand Opera. She is currently based in London and is studying piano accompaniment with Eugene Asti and Pamela Lidiard at the Guildhall School of Music and Drama, where she was the winner of the 2010 Paul Hamburger Prize for voice and piano duo and the 2011 Cunard Piano Accompaniment Prize.


DVDs/Blu-rays Reviews TV
Game Of Thrones The Complete Sixth Season Blu-ray, DVD Review
November 14, 2016 November 14, 2016 Paul Semel 0 Comments Blu-rays, DVDs, Fantasy, Game Of Thrones Season 6, Game Of Thrones Season Six, Game Of Thrones The Complete Sixth Season, Game Of Thrones The Complete Sixth Season Blu-ray, Game Of Thrones The Complete Sixth Season Blu-ray Amazon, Game Of Thrones The Complete Sixth Season Blu-ray DVD review, Game Of Thrones The Complete Sixth Season Blu-ray release date, Game Of Thrones The Complete Sixth Season Blu-ray review, Game Of Thrones The Complete Sixth Season digital download, Game Of Thrones The Complete Sixth Season digital HD, Game Of Thrones The Complete Sixth Season DVD, Game Of Thrones The Complete Sixth Season DVD Amazon, Game Of Thrones The Complete Sixth Season DVD release date, Game Of Thrones The Complete Sixth Season DVD review, HBO, Reviews
Every time HBO Home Video releases the latest season of Game Of Thrones on Blu-ray and DVD, I get a thrill rewatching the episodes as they were meant to be seen, enjoy the special features, and then lament that some of the latter aren't set up correctly or aren't where they should be, and why are some are left off the DVD version? Not surprisingly, that's exactly how I feel about Game Of Thrones The Complete Sixth Season (Blu-ray, DVD). Well, except for that one other huge mistake they made this time around.
For those who missed this season, the ten episodes in Game Of Thrones The Complete Sixth Season mark the first time that this show isn't entirely based on George R.R. Martin's original novels. Granted, this show has often diverged from those sacred texts, but with the sixth book, The Winds Of Winter, still not out, the show does explore some uncharted waters. That said, Martin is still involved in the show, and has not only told the writers what happens in that unpublished novel, but they're also still pulling some material from the fourth and fifth books, A Feast For Crows and A Dance With Dragons.
As for what happens in these episodes, Game Of Thrones The Complete Sixth Season starts with Sansa arriving at The Wall, only to learn that Jon Snow is dead; Cersei dealing with The High Sparrow and her followers in that most Cersei of ways; Arya coming to grip with her blindness; Tyrion and Varys trying to run Mereen without Daenerys; Daenerys trying to make her way back to Mereen; and Ramsey Bolton continuing to run his castle like a tyrant. Along the way, there are some shocking moments, some explosive ones, and a lot of characters learning how their stories end. Which is usually not well.
Visually and aurally, the episodes included in the Game Of Thrones The Complete Sixth Season look and sound great, especially on Blu-ray. Plus, you don't have to deal with any stuttering or other problems because someone in your house is trying to stream the new Metallica album or is playing Call Of Duty: Infinite Warfare. They even include HBO's previews for the episodes, as well as the recaps of previous episodes, for those who, I guess, really want to recreate the experience of watching this show live.
Along with the ten episodes, Game Of Thrones The Complete Sixth Season has the same kind of extras they included in the Game Of Thrones The Complete Fifth Season, Game Of Thrones The Complete Fourth Season, and so on. Well, mostly.
For starters, Game Of Thrones The Complete Sixth Season has thirteen commentary tracks, including two each on the episodes "The Door" (which is the fifth), "Battle Of The Bastards" (the ninth), and "The Winds Of Winter" (the tenth). As always, these conversations mostly fun and informative, thanks to them pairing crew members with such actors as Peter Dinklage (Tyrion Lannister), Natalie Dormer (Margaery Tyrell), and Ian McShane (who guested this season as Brother Ray), something that always keeps commentaries from turning into Film Theory 101. The exception to this being the aforementioned secondary commentaries on episodes five, nine, and ten, since they just have crew people, no cast.
Game Of Thrones The Complete Sixth Season also has three making-of featurettes for those who want to see how the sausage was made. In "The Battle Of The Bastards: An In-Depth Look," the cast and crew spend half-an-hour talking about the climactic battle at the end of this season; "18 Hours At The Paint Hall" is a twenty-eight minute look at when all three filming units were working at the show's studios, something that usually doesn't happen given how much is shot on location; while the twenty-minute-long "Recreating The Dothraki World" discusses how they rebuilt Dothraki society. As always, all three are informative and entertaining, though without becoming too academic.
The Blu-ray and DVD editions of Game Of Thrones The Complete Sixth Season also have three deleted scenes. None of which change anything, mind you — it's not like one has the camera pulling out to reveal that Westeros is actually part of Westworld — but they are more than just little snippets of cut, inconsequential dialog. That said, I'm glad they excised the last one, "The Play," which shows a longer version of, well, the play. What was in the episode was quite enough.
While all of those special features are included in both the Blu-ray and DVD versions of Game Of Thrones The Complete Sixth Season, the former also has two extras not included in the latter. The "In-Episode Guide," which runs concurrent with whatever episode you're watching, shows relevant pop-up factoids about whatever is happening in that specific scene. Though unlike watching an episode of that show Pop-Up Video, or any show where they insist on interacting live with Twitter, you decide when you'd like to learn something, and when you wouldn't.
The Game Of Thrones The Complete Sixth Season Blu-ray also has "Histories And Lore," in which such actors as Nikolaj Coster-Waldau (Jaime Lannister), Sophie Turner (Sansa Stark), and Jonathan Pryce (The High Sparrow) explain, in character, the mythology of Westeros and Essos. Which sure as hell beats looking it up on Wikipedia.
While the extras included on the Game Of Thrones The Complete Sixth Season Blu-ray are good — and the DVD slightly less so — they're far from what they should be. For starters, the deleted scenes are all lumped together on the last disc, as opposed to in the section for the episode from which it came. There's also nothing to indicate from which episode they were cut, where in that episode they were excised from, and why they were deleted from the final version.
Similarly, the "Recreating The Dothraki World" featurette is on the second disc, not the last, even though it's something you shouldn't watch until you've seen all of the episodes.
The Game Of Thrones The Complete Sixth Season also could've benefitted from an extra along the lines of "The Fallen: A Roundtable," a featurette on Game Of Thrones The Complete Fourth Season in which most of the actors whose characters died that season got together to talk about their time on the show…and to pretend they weren't pissed that their character had been killed off.
But the most annoying thing about the special features on Game Of Thrones The Complete Sixth Season Blu-ray and DVD is that both are missing extras that are included in the Digital HD version: "Bran's Journey," a nine-minute featurette on what Bran endured this season; the self-explanatory "Inside Game of Thrones: Prosthetics"; and "The Game Revealed," which is identified in the press materials as being a, "Five-part series covering the creation of Season 6's most epic set pieces and scenes." Though as I don't have the digital HD version, I can't comment on their quality.
Though even if they're dull, though, leaving these extras off the Blu-ray and DVD of Game Of Thrones The Complete Sixth Season is inexcusable and annoying, and not just because the word "Complete" is right there in this collection's title. It's also irritating because we all know that at some point there will be a version of Game Of Thrones The Complete Sixth Season or an all-inclusive Game Of Thrones The Complete Series collection that includes these extras.
Despite these shortcomings, thought, Game Of Thrones The Complete Sixth Season Blu-ray and DVD are still the best way to watch these episodes. Sure, the special features could be a bit more special, or at least complete, but if you're just into this for the show itself, this will do quite nicely…for now.
SCORE: 8.0/10
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Tech Transformers
Has California slammed the brakes on driverless cars?
Published Fri, Dec 18 20152:56 AM EST Updated Fri, Dec 18 201510:38 AM EST
Arjun Kharpal
California proposal could slow down Google's driverless car
California's proposal to make driverless cars have someone at the wheel are "perplexing" and could hamper the progress of the technology, Google said on Thursday.
Earlier this week, the California Department of Motor Vehicles (DMV) proposed draft rules that would require a licensed driver "to be present inside the vehicle and be capable of taking control in the event of a technology failure or other emergency".
In a blog post published late Thursday, Google's head of self-drive division, Chris Urmson, slammed the decision. "This maintains the same old status quo and falls short on allowing this technology to reach its full potential, while excluding those who need to get around but cannot drive," Urmson wrote.
"While we're disappointed by this, we will continue to work with the DMV as they seek feedback in the coming months, in the hope that we can recapture the original spirit of the bill.
"California is a state with both world-class car culture and world-class innovation, and we can do better."
California has been one of the most accommodative states in regards to driverless cars. In 2012, legislators passed a bill that allowed self-driving cars to operate with or without a driver and since then, Google claims to have driven its vehicle over 1.3 million miles. Google said the California DMV "seemed to shrink back from its leadership" with its new proposals.
A key concern for users and regulators is the fact that its driverless prototype has no steering wheel or pedals -- in spite of the U.S. search giant's regular reassurances of the safety of its cars. In its monthly report on its self-driving car project for November, Google explained how its cars have built up a "library of various sirens" and taught its software to identify them, so when an emergency vehicle approaches, the cars will "drive more conservatively until it has a better sense of where the sirens are coming from.
Google also said that its vehicle had been involved in "17 minor accidents" in six years of the project but never been the cause of one.
Other proposals from the California DMV include third-party testing of the vehicles and the obligation for manufacturers to alert the operator of a car to a cyber attack.
Two public consultations about the laws are being held early next year.
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Opioid Epidemic Changes, Challenges Police Departments
The opioid crisis has changed the way police departments around the nation are interacting with people who use drugs.
In Burlington, Vermont a man was overdosing on opioids for the second time in 10 days. Even as a police officer followed him to the emergency room, the man tried to resist help. The officer, however, insisted.
"If you need help, we'll drive you to treatment right now," the officer told the man.
The incident is just one example of how police departments around the nation are changing how they interact with those who use drugs. According to a New York Times report, police around the country are struggling to help people who use drugs while also keeping up with the demands of an epidemic that is killing people at the highest rates ever.
In Burlington, police launched an initiative called SubStat—for tracking users who move into neighboring communities—and hired an opiate policy coordinator for the department.
"It's all about shifting from addiction as a crime to addiction as a disease," said Jane Helmstetter of Vermont's human services agency.
The man who overdosed found himself working with the opiate police coordinator and the chief of police in order to access treatment. The positive interaction surprised the man's mother, who asked to remain anonymous.
"He wasn't just treated as a drug addict and someone that wasn't worthy of help," she said. "Here you have a police chief sitting in the same room with a drug addict that knowingly uses illegal substances and he's not going to handcuff him? It was unusual."
Unlike the crack cocaine epidemic of the late '80s, the opioid epidemic has brought around a realization that a strict law-and-order policy on its own cannot stop drug addiction.
"The police can play a critical role in a very broadly based social and medical response," said Samuel Walker, an emeritus professor of criminal justice at the University of Nebraska Omaha. "So if people think we are going to arrest our way out of the opioid crisis, they're wrong."
However, despite a more compassionate attitude toward addiction, police officers maintain that drugs often lead to violence, and they do not shy away from that reality in the opioid epidemic.
"In almost all of our major seizures and arrests, we're encountering weapons," said Chuck Rosenberg, acting head of the Drug Enforcement Administration (DEA). "And there's only one reason to have those around."
Officers who respond to hundreds of overdose calls each year are also dealing with compassion fatigue as overdose rates continue to climb.
"We've been at this for, now, four or five years, and the overdose numbers continue to go up," said Chuck Wexler, the executive director of the Police Executive Research Forum. "What's going to be the defining moment to move this in a different direction?"
Last month, Wexler facilitated a conference in New York City for law enforcement leadership. There, officers talked about how best to fight the epidemic and also about the nuances of doing so. How can officers tell whether someone is a user in need of treatment or a mid-level dealer? How can officers take a compassionate approach to low-level offenders when Attorney General Jeff Sessions is mandating harsher sentencing?
At the conference, J.Scott Thomson, the police chief in Camden, New Jersey, presented a grim outlook: "We are still losing," he said.
overdose deaths
They Fell In Love Helping Drug Users. But Fear Kept Him From Helping Himself.


THE LITTLE ART THEATER- The campus home of early 1960s sexploitation films
Poolside scene from an early 1960s nudist movie. Most nudist pictures used models and actors with actual nudists only as extras.
In the early 1960s, the Little Art Theater, 2523 N. High (about where O'Reilly Auto Parts is today), was the campus home for nudist exploitation features.
The Little Art Theater opened as the Piccadilly way back in 1918. It may have some connection to the Crystal Theater nearby, the very first motion picture theater in the University District. The Piccadilly showed pictures from the era of the silents right up through the Golden Age of Hollywood. In 1940, it became The Olentangy and, in 1949, after briefly going as The World (before that name moved south down High St. to the former Alhambra) changed its name to The Little Art Theater.
In the late 1940s, something happened. Television came along. Movie attendance plummeted. Box office crashed. Theater after theater closed as audiences stayed home to watch I Love Lucy and Arthur Godfrey's Talent Scouts on their new TVs. Small neighborhood theaters were especially hard hit.
For dying theaters to survive, they had to find a niche. They had to offer theatergoers something they couldn't get on their TV sets at home. For theaters like The Little Art, that something was nudity.
Newspaper advertisements for the Little Art Theater from the 1960s.
In 1954, a picture called Garden of Eden, was released. The story of an abused war widow who finds freedom and happiness in a nudist colony, Garden of Eden featured abundant nudity and met with numerous censorship efforts. Garden of Eden's producers fought back. In 1957, in Excelsior Pictures Corporation vs. Regents of the State University of New York, the courts ruled that filmed nudity was not inherently obscene, so long as it was not complete and its purpose wasn't solely to titillate.
The specific and limited portions of the film to which the licensing authorities object are exposed portions of human bodies in scenes depicting a nudist colony. There is, however, no full exposure of any adult nude body. The objectionable aspect of the film does not reach a magnitude which, under the limitations with which the Supreme Court has covered over the power of a State to censor films, would warrant prior restraint.
The floodgates opened and America was soon awash in nudist pictures.
The obligatory volleyball scene. Every nudist film had one. No full frontal nudity was allowed so the team facing towards the camera always wore bottoms.
The pictures told stories that had to be told and just happened to demand a nudist camp setting in order to tell the story. There were nudist exposés (The Nudist Racket Exposed, Nature Camp Confidential), nudist advocacy (Gentlemen Prefer Nature Girls), nudist musicals (Goldilocks and the Three Bares), nudist historical romances (My Bare Lady), stories about robbers who hide out in nudist camps (Hideout in the Sun), nudist spy movies (Behind the Nude Curtain), outer space nudists (Nude on the Moon), celebrity nudists (The Wild Wild World of Jayne Mansfield, Blaze Starr Goes Nudist), nudist travelogues (Naked As Nature Intended, Isle of Levant), even nudists vs. monsters (Monster of Camp Sunshine).
Demand for nudist-sploitation feature was so brisk that director Doris Wishman made a career out of nudist films, producing eight of them between 1960 and 1964.
And The Little Art profitably exhibited them all.
The nudie-cutie trend played itself out by the mid-1960s and gave way to stronger stuff. The Little Art followed suit and was soon exhibiting X-rated features. By the 1970s, the city decided the theater was a blight on the neighborhood and attempted to use code enforcement to shut it down.
The theater owners fought the action in the courts and took it all the way to the US Supreme Court. But that's another story...