How do general practitioners manage alcohol-misusing patients? Results from a national survey of GPs in England and Wales

The appropriateness of the primary care setting to undertake health promotional activities has been emphasized, but little is known about the clinical work of GPs with patients misusing alcohol. This study examines how GPs managed alcohol-misusing patients. A 20% random sample of all general practitioners in England and Wales were surveyed using a postal questionnaire. A 44% response rate was achieved. GPs reported managing different levels of severity of drinking problems differently. Basic interventions, such as reporting the alcohol misuse diagnosis and the provision of advice and information, were routine. Health promotion leaflets were not used uniformly, even with the less severe problem drinkers. Detoxification, prescribing of drugs and the management of medical complications were undertaken mainly with dependent patients. Dependent drinkers were the most likely group to be referred to specialist services, while internal practice referrals occurred with all drinking status categories. Anti-depressants were the drugs most usually prescribed to alcohol-misusing patients. The data point to a need for basic guidelines, not only on how to manage and refer dependent drinkers, but also on how to detect and manage those who are not yet manifesting problems but are drinking above recommended guidelines. One of the most evident areas in which there appears to be a need for guidelines is that of prescribing within primary care.

Low detection rates, negative attitudes and the failure to meet the "Health of the Nation" alcohol targets: findings from a national survey of GPs in England and Wales

The appropriateness of the primary care setting to undertake the health promotional activities needed to meet 'Health of the Nation' alcohol targets has been acknowledged in UK government policy and the scientific literature. However, the latest data suggest these targets are not being met. A 20% random sample of all general practitioners in England and Wales were surveyed by postal questionnaire to examine their work in detecting alcohol misuse and their attitudes towards the work. Four mailing waves produced a 44% response rate. GPs had identified a mean of 3.2 patients per month drinking above recommended 'sensible' guidelines. These patients were mostly male (73%) and above 40 years of age (45%), with nearly half (45%) already dependent drinkers. Most GPs perceived alcohol misuse patients as a difficult group with whom to work. None the less, over half the respondents believed general practice was an appropriate setting for the detection of the problem. However, most did not feel trained or supported in this area of their work. More emphasis needs to be placed on the valuable contribution GPs can make with the larger number of patients who are drinking regularly above 'sensible' levels but not yet suffering adverse affects. Our findings point towards not an unwilling profession, but a profession lacking confidence. The provision of support and basic training are major factors in how GPs perceive alcohol misusers and their own role in this work. Twenty years after the Maudsley Alcohol Pilot Project research it is disappointing that, despite greater recognition by GPs of their potential impact, lack of training and lack of support are still so central to their continued low levels of therapeutic commitment.

Surfactant boundary lubricant film modified by an amphiphilic diblock copolymer

The effect of the uptake of a low-molecular-weight amphiphilic diblock copolymer on the morphology of didodecyldimethylammonium bromide (DDAB) adsorbed layers on mica, the interactions between two coated surfaces, and the frictional properties of the boundary film have been studied using an atomic force microscope and a dynamic surface forces apparatus nanotribometer. When DDAB-coated surfaces in aqueous solution were compressed, hemifusion or removal of the adsorbed surfactant bilayers could not be induced, and no frictional force could be measured between the surfaces, which display superior lateral cohesion and lubricant properties. Coadsorbing octadecyl end modified poly(ethylene oxide) chains at low density facilitates hemifusion, generating significant shear stress and leading to stick-slip instabilities. The mixed films regain their lateral cohesion at higher adsorbed copolymer densities, but an extra short-range attraction brings the adsorbed layers into adhesive contact without causing bilayer hemifusion. Here, noticeable frictional forces are also measured.

Behavior of adhesive boundary lubricated surfaces under shear: effect of grafted diblock copolymers

The shear behavior and the normal interaction between mica surfaces covered by surfactant or surfactant-polymer mixtures were studied with a Surface Forces Apparatus (SFA) nanotribometer. If the surfaces are compressed while fully immersed in an aqueous surfactant solution that adsorbs in the form of flat bilayers, hemifusion can be induced. When the hemifused surfaces are subject to shear, at least five different dynamic regimes can be recognized. The general behavior may be described by a model based on the kinetics of formation and rupture of adhesive bonds between the shearing surfaces, with an additional viscous term. Once the adsorbed surfactant layer is decorated with physigrafted copolymers, the number of sliding regimes may be reduced to only one, in which the shear stress increases sublinearly with the driving velocity. The adhesion energy and the resistance to hemifusion of the adsorbed surfactant-polymer layers are also strongly modified as the grafting density increases.

Friction between two weakly adhering boundary lubricated surfaces in water

The sliding of adhesive surfactant-bearing surfaces was studied with a surface forces apparatus nanotribometer. When the surfaces are fully immersed in an aqueous solution, the dynamic behavior is drastically different and more varied than under dry conditions. In solution, the shear stress exhibits at least five different velocity regimes. In particular, the sliding may proceed by an "inverted" stick-slip over a large range of driving velocities, this regime being bounded by smooth (kinetic) sliding at both lower and higher driving velocities. The general behavior of the system was studied in detail, i.e., over a large range of experimental conditions, and theoretically accounted for in terms of a general model based on the kinetics of formation and rupture of adhesive links (bonds) between the two shearing surfaces with an additional viscous term.

Accelerating Reinforcement Learning by Composing Solutions of Automatically Identified Subtasks

This paper discusses a system that accelerates reinforcement learning by using transfer from related tasks. Without such transfer, even if two tasks are very similar at some abstract level, an extensive re-learning effort is required. The system achieves much of its power by transferring parts of previously learned solutions rather than a single complete solution. The system exploits strong features in the multi-dimensional function produced by reinforcement learning in solving a particular task. These features are stable and easy to recognize early in the learning process. They generate a partitioning of the state space and thus the function. The partition is represented as a graph. This is used to index and compose functions stored in a case base to form a close approximation to the solution of the new task. Experiments demonstrate that function composition often produces more than an order of magnitude increase in learning rate compared to a basic reinforcement learning algorithm.

Sarcoidosis with prominent giant cells

A 31-year-old man presented with a widespread papular eruption and systemic symptoms including renal colic and decreased exercise tolerance. The combination of clinical features and laboratory investigations that revealed an elevated angiotensin converting enzyme level and hypercalcaemia enabled a diagnosis of sarcoidosis to be made. Multiple skin biopsies showed prominent Touton-like giant cells which delayed the diagnosis. Giant cells are frequently seen in sarcoidal granulomas but in some cases their prominence and Touton-like appearance may suggest alternative diagnoses such as xanthogranulomas.

Dynamic phase transitions in confined lubricant fluids under shear

A surface force apparatus was used to measure the transient and steady-state friction forces between molecularly smooth mica surfaces confining thin films of squalane, C30H62, a saturated, branched hydrocarbon liquid. The dynamic friction "phase diagram" was determined under different shearing conditions, especially the transitions between stick-slip and smooth sliding "states" that exhibited a chaotic stick-slip regime. The apparently very different friction traces exhibited by simple spherical, linear, and branched hydrocarbon films under shear are shown to be due to the much longer relaxation times and characteristic length scales associated with transitions from rest to steady-state sliding, and vice versa, in the case of branched liquids. The physical reasons and tribological implications for the different types of transitions observed with spherical, linear, and branched fluids are discussed.

Are practice nurses an unexplored resource in the identification and management of alcohol misuse? Results from a study of practice nurses in England and Wales in 1995

Changes in the health promotional work undertaken in primary care, including the work needed to meet the 'Health of the Nation' alcohol targets, have led to a rapid expansion of the number of practice nurses in England and Wales. However, there has been little evaluation of this role. This study provides data, for the first time at a national level, about practice nurses' work in identifying and managing patients drinking above recommended sensible guidelines. Data were collected by postal questionnaire from all nurses in a 50% random sample of 1852 practices (drawn from a general practitioner (GP) national study, undertaken at the same time). 43% of nurses responded from 62% of the targeted practices. Respondents reported identifying a mean of 3.1 patients per month who were drinking above recommended sensible guidelines. These patients tended to be male, above 40 years of age and in contact with the nurse for the first time about this problem. Most patients were categorized as having a potential alcohol problem; few were classified as currently dependent. Very little intervention work was undertaken by nurses except for referral to the GP. If real progress is to be made in meeting the 'Health of the Nation' targets on population alcohol consumption, then primary care work in identifying alcohol misusing patients needs to be developed as a matter of urgency. The patients identified by practice nurses are those patients relevant to the 'Health of the Nation' alcohol targets. More emphasis needs to be placed on the valuable contribution practice nurses can make, particularly through the use of screening instruments and brief interventions.

The effect of cash and other financial inducements on the response rate of general practitioners in a national postal study

BACKGROUND

Low response rates are acknowledged as a potential source of bias in survey results. Response rates are a particular problem in surveys of GPs. Thus, the methods used to encourage response to mailed surveys and the influence of inducements in maximizing response rates are fundamental issues to be examined when addressing the problem of response bias.

AIM

To increase the overall response rate to a national study of GPs and to explore the effects of financial and non-financial inducements on response rates.

METHODS

Two mailing waves of a postal questionnaire to a 20% random sample of all GPs in England and Wales had achieved a 33% response rate. For the third mailing wave, the non-responding GPs were then divided into a control group, a group who were offered a donation to charity to complete the questionnaire and a group who were offered cash. The charity and cash groups were further subdivided into 5 pounds and 10 pounds groups to assess the effect of the size of the inducement offered. For the control group, a fourth wave was sent the offer of a 5 pounds or 10 pounds incentive.

RESULTS

Response was positively affected by the offer of an inducement. Cash, however, had a more substantial effect than the offer of a donation to charity. Older GPs were less likely to participate overall, whereas male GPs were more likely to respond to a cash inducement. Doctors who had seen more patients were less likely to reply earlier and were more likely to respond to the offer of cash.

CONCLUSIONS

Primary care is going through many changes, some of which have increased the workload of the GP. It may now be that, to achieve the response rates needed to validate policy-related research, the offer of inducements will become a necessary part of the research process.

Surveying general practitioners: does a low response rate matter?

BACKGROUND

Primary care has long been of interest to policy research. Recently, there is evidence to suggest that it is becoming more difficult to encourage GPs (general practitioners) to participate in surveys. As low response rates can introduce bias into survey results, it is important to study the effects of non-response.

AIM

To assess the validity of a response rate of 44% obtained in a national postal study of GPs surveyed about their work with alcohol-misusing patients by assessing the extent of any non-response bias.

METHOD

A telephone survey of 148 GPs who had not responded to repeated mailings of a postal questionnaire was undertaken. In addition to personal and practice structure characteristics, the GPs were asked three questions taken from the original questionnaire about their work with alcohol-misusing patients.

RESULTS

Of the 148 GPs telephoned, 64 responded to the telephone questionnaire in full; all had previously failed to respond to the postal questionnaire. Younger GPs were more likely to respond to both the national postal and telephone surveys, but more so to the latter. Telephone responders were more likely to be GPs in a single-handed practice. The work of GPs with alcohol-misusing patients highlighted differences between the two response groups. Male telephone responders were found to be identifying a significantly higher average of alcohol misusers than male postal responders. Telephone responders were more likely to feel trained in treating alcohol misuse and to feel better supported to deal with this patient group.

CONCLUSION

Some significant differences were identified, indicating the presence of non-response bias. A low response rate need not affect the validity of the data collected, but it is still necessary to test for non-response effects and make corrections to the original data in order to maximize validity.

Alcohol as an unconditioned stimulus in human classical conditioning

Recent experiments with human subjects have shown that drug cues (e.g. sight of beer or needle and syringe) elicit different responses than do neutral stimuli. However, because conditioning has not been carried out in the majority of cases, it is not clear why drug cues have different response eliciting capacities; associative and nonassociative mechanisms may both play a part. In this experiment a counterbalanced differential conditioning procedure was used to isolate the role of associative processes in the development of physiological, behavioural, and subjective conditioned responses to cues for alcohol over the course of repeated conditioning sessions. Twelve healthy volunteers took part in the experiment which involved each subject attending for ten sessions. On physiological measures evidence was found for conditioning of skin conductance and cardiac inter-beat interval responses to cues for alcohol delivery. Over the course of conditioning on behavioural measures of drink consumption there were changes in the rate of consumption and number of sips taken as a function of whether or not the drinks contained alcohol. Finally, on subjective measures, there was a differential change in subjective state in response to alcohol and soft drink expectancy as conditioning progressed.

Medical and psychiatric needs of adults with a mental handicap

This study describes the assessment of the medical and psychiatric needs of adults with a mental handicap recently resettled in community facilities including 'staffed houses'. No statistically significant differences were found for behaviour problems and psychiatric diagnosis prior to resettlement and one year after. However, increased use of primary care and expert psychiatric service were found following the resettlement. Clinical and service issues in relation to successful maintenance of people with mental handicap in the community are discussed.

The use of services for alcohol problems: general practitioner and specialist alcohol clinic

A sample of 40 patients referred to a specialist alcohol clinic were given a full assessment by a clinician and then randomly allocated to one of two groups. The first group received continuing care from the clinic. The second group were returned to the management of their general practitioners who were offered specialist support in caring for their patients. Patients and general practitioners were followed-up 6 months after the clinic assessment. This paper reports on the uptake of clinic and general practice services by patients and examines the possible factors associated with continuing attendance, including patient attributes, service activity, patients' self-assessments of their drink problem and their expectations of help from services. Qualitative data is used to examine patients' perceptions and experiences of clinic and general practice-based care for drinking problems. The findings highlight some of the difficulties reported by patients in receiving help for their problems particularly from general practitioners.

Engaging patients with alcohol problems in treatment: the first consultation

This paper considers the impact of the first consultation at a specialist alcohol clinic on patients' perceptions of their drink problem and on their expectations of help from three sources: an alcohol clinic, general practitioners and Alcoholics Anonymous. At intake, males had higher expectations than females of help from the alcohol clinic while people in manual occupations and those in the 'less heavy' drinking category had higher expectations of general practitioner help than other patients. Change was found to occur during the first clinic consultation so that by the end of the session patients had raised their rating of problem severity and their expectations of help from the three sources examined. Overall, patient perceptions of the clinic assessment session were positive. The study highlights the importance of obtaining a full understanding of the process of engagement in treatment and indicates the potential of a clinical assessment to effect change in patient attitudes.

Alcohol consumption, problem drinking and anti-social behaviour in a sample of college students

A total of 125 male and 145 female students completed a written questionnaire (response rate 68%) on their consumption levels and patterns, problem drinking and vandalism and assaults associated with drinking, Prevalence of heavy drinking was broadly similar to that found in other college student samples in the UK with 25.6% of male students and 14.5% of female students drinking more than their safe limits of 35 and 21 units per week respectively. Six percent of male and one percent of female students exceeded the problem drinking threshold on the MAST. Twenty percent of the male students and 6% of the females admitted having caused at least some damage to property after having been drinking in the past 12 months. Four percent of males and 5% of females admitted 'minor' assaults. Fifty percent of males and 36% of females had witnessed damage to property and 19% of males and 10% of females had experienced some kind of assault. Vandalism and assaults were positively and independently associated with higher levels of consumption, reasons for drinking and patterns of drinking; in particular morning drinking appeared to play a role. Taking amount of drinking into account, males were more likely to commit acts of vandalism but females were more likely to commit assaults. The results reveal that alcohol-related, anti-social behaviour among students is a significant problem and that, while heavy drinking per se plays a role, other factors are also important.