'DrinkThink' alcohol screening and brief intervention for young people: a qualitative evaluation of training and implementation

Background

Alcohol Screening and Brief Intervention (ASBI) helps reduce risky drinking in adults, but less is known about its effectiveness with young people. This article explores implementation of DrinkThink, an ASBI co-produced with young people, by health, youth and social care professionals trained in its delivery.

Methods

A qualitative evaluation was conducted using focus groups with 33 staff trained to deliver DrinkThink, and eight interviews with trained participants and service managers. These were recorded, transcribed and a thematic analysis undertaken.

Results

DrinkThink was not delivered fully by health, youth or social care agencies. The reasons for this varied by setting but included: the training staff received, a working culture that was ill-suited to the intervention, staff attitudes towards alcohol which prioritized other health problems presented by young people, over alcohol use.

Conclusions

Implementation was limited because staff had not been involved in the design and planning of DrinkThink. Staffs' perceptions of alcohol problems in young people and the diverse cultures in which they work were subsequently not accounted for in the design. Co-producing youth focused ASBIs with the professionals expected to deliver them, and the young people whom they target, may ensure greater success in integrating them into working practice.

Rolling out HIV antiretroviral therapy in sub-Saharan Africa: 2003-2017

Multiple issues need to be addressed in order to control the HIV pandemic in sub-Saharan Africa. Combination antiretroviral therapy (cART) is key to reducing morbidity and mortality among people living with HIV and has a role in preventing HIV transmission. However, access to cART is very unevenly distributed globally, especially in sub-Saharan Africa. Although cost of cART is no longer a major barrier as effective treatment can be had for under US$100 per year, HIV management is compromised by the inadequate number of trained clinicians, the lack of clinical and laboratory infrastructure and the increased prevalence of co-morbidities (e.g., tuberculosis). To address this disparity, a number of initiatives have been undertaken. One of these was the development of the Infectious Diseases Institute (IDI) at Makerere University, Kampala, Uganda. The goals of the IDI are the clinical care of people living with HIV, clinical research relevant to Uganda (in particular) and sub-Saharan Africa, and clinical training. My initial participation was as a trainer in a program to educate large numbers of clinicians in antiretroviral therapy and other aspects of HIV/AIDS management, with the intention that they become leaders of large clinical programs in their home communities. Major progress has been made in providing access to cART, and HIV/AIDS mortality and incidence of new cases is decreasing. Nevertheless, to reach the World Health Organization 90-90-90 targets by 2020, there remains a need to expand services and develop novel approaches to HIV management. In addition to providing hands-on clinical care, Canadian health care providers can help by transferring clinical skills to local clinicians or by developing streamlined clinical paradigms or new technologies for long-term HIV management in resource-limited settings.

Mycobacterium chimaera Infection After Aortic Valve Replacement Presenting With Aortic Dissection and Pseudoaneurysm

We present a case of Mycobacterium chimaera infection presenting with aortic dissection and pseudoaneuysm in a 22-year-old man with a past history of aortic valve replacement. Clinicians should consider M. chimaera infection in those presenting with aortic dissection as a late complication of cardiovascular surgery.

The safety and efficacy of benzbromarone in gout in Aotearoa New Zealand

BACKGROUND

Benzbromarone is a potent uricosuric but is not widely available due to concerns about hepatotoxicity. In Aotearoa New Zealand, benzbromarone has been available since April 2013, subject to funding restrictions, for patients with inadequate urate-lowering response or intolerance to allopurinol and probenecid.

AIM

To assess the safety and efficacy of benzbromarone in a real-life setting.

METHODS

All patients who received funding for benzbromarone from 1 April 2013 to 30 September 2014 were identified. Prescribers were sent a questionnaire for each individual. Information on demographics, efficacy of previous urate-lowering drugs and reasons for discontinuation were collected. Specific information about the dose, effect on serum urate, adverse effects and liver function tests after commencing benzbromarone was recorded.

RESULTS

Completed questionnaires were returned for 123 of 164 (75%) patients. Mean (SD) serum urate prior to benzbromarone was 0.57 (0.12) mmol/L, and estimated glomerular filtration rate was 50.3 (22.8) mL/min/1.73 m(2) . The median dose of benzbromarone was 100 mg/day (25-200 mg/day). Six months after commencing benzbromarone, mean (SD) serum urate was 0.35 (0.12) mmol/L. Benzbromarone-related adverse events included rash (n = 4), diarrhoea (n = 9), nausea (n = 6) and urate stones (n = 3). Liver function test abnormalities were uncommon and tended to be mild. There were 14 patient deaths; none was considered related to benzbromarone. Allopurinol had been prescribed prior to benzbromarone in 117 of 123 patients; median maximum allopurinol dose was 200 mg/day (range 25-600 mg/day), and 19% patients received allopurinol >300 mg/day.

CONCLUSION

Benzbromarone provides useful urate-lowering efficacy and does not appear unsafe in patients with gout. Urate-lowering therapy prescribing requires further optimisation.

[Management of the bleeding risk associated with antiplatelet agents]

Like all antithrombotic drugs, antiplatelet agents expose to a risk of bleeding complications. Clinical research has extensively focused on the efficacy of these drugs to reduce ischemic events. The bleeding risk associated with them was solely considered as an inevitable and acceptable complication. When two new potent P2Y12-receptor inhibitors, prasugrel and ticagrelor, were marketed, the risk of major bleeding increased. These new agents have modified the balance between the absolute risk reduction in ischemic events and the absolute risk increase in bleeding events. This paper is an update on the bleeding risk assessment associated with antiplatelet agents. It discusses the place of platelet function monitoring, and the optimal management of bleeding complications. It addresses the challenging issue of reversal of antiplatelet therapy, focusing especially on ticagrelor, which pharmacodynamics complicate bleeding management.

An evaluation of the absolute and relative stability of alexithymia over 11years in a Finnish general population

OBJECTIVE

We investigated if alexithymia, a personality construct with difficulties in emotional processing, is stable in the general population.

METHODS

Altogether 3083 unselected subjects aged 30 and older in Finland completed the 20-item Toronto Alexithymia Scale (TAS-20) in the longitudinal Health 2000 and Health 2011 general population surveys (BRIF8901). The stability of alexithymia at the 11-year follow-up was assessed with t-tests, correlations, and separate linear regression models with base-line and follow-up age, gender, marital status, education, and 12-month depressive and anxiety disorders as confounders.

RESULTS

The mean score (SD) of the TAS-20 for the whole sample was 44.2 (10.4) in 2000 and 44.2 (10.9) in 2011 (p=0.731). The mean score of the TAS-20 subscale Difficulty Identifying Feelings increased by 0.3 points, Difficulty Describing Feelings decreased by 0.6 points and Externally Oriented Thinking increased by 0.3 points. The effect sizes of the changes varied from negligible to small. Age had little effect except for the group of the oldest subjects (75-97years): the TAS-20 mean (SD) score was 49.1 (10.1) in 2000 and 53.1 (10.3) in 2011 (p<0.001), the effect size for the increase was medium. TAS-20 score in 2000 explained a significant proportion of variance in TAS-20 score in 2011. Controlling for all baseline confounders improved the model incrementally; the same applied to controlling for confounders at follow-up. Baseline depression or anxiety disorders were not associated with the TAS-20 scores in 2011, whereas current diagnoses were.

CONCLUSIONS

According to our large longitudinal study both the absolute and relative stability of alexithymia assessed with the TAS-20 are high in the adult general population.

Impact of Modified TICI 3 versus Modified TICI 2b Reperfusion Score to Predict Good Outcome following Endovascular Therapy

BACKGROUND AND PURPOSE

The TICI score is widely used to evaluate cerebral perfusion before and after the endovascular treatment of stroke. Recent studies showing the effectiveness and safety of mechanical thrombectomy combine modified TICI 2b and modified TICI 3 to assess the technical success of endovascular treatment. The purpose of this study was to determine how much clinical outcomes differ between patients achieving modified TICI 2b and modified TICI 3 reperfusion.

MATERIALS AND METHODS

We analyzed 222 consecutive patients with acute large intracranial artery occlusion of the anterior circulation having achieved modified TICI 2b or modified TICI 3 reperfusion after thrombectomy. The primary end point was the rate of favorable outcome defined as the achievement of a modified Rankin Scale score of 0-2 at 3 months.

RESULTS

Patients with modified TICI 3 more often had favorable collateral circulation and atherosclerosis etiology, with a shorter time from onset to reperfusion than patients with modified TICI 2b (all P < .05). The number of total passes to achieve reperfusion was higher in the modified TICI 2b group (median, 2; interquartile range, 1-3, 1-9) versus (median, 1; interquartile range, 1-2, 1-8) in the modified TICI 3 group (P = .0002). Favorable outcome was reached more often for patients with modified TICI 3 than for those with modified TICI 2b (71.7% versus 50.5%, P = .001), with a similar difference when considering excellent outcome. In addition, patients with modified TICI 3 had a lower intracerebral hemorrhage rate (23.0% versus 45.0%, P < .001).

CONCLUSIONS

Patients with modified TICI 3 reperfusion have better functional outcomes than those with modified TICI 2b. Given the improving reperfusion rates obtained with thrombectomy devices, future thrombectomy trials should consider modified TICI 2b and modified TICI 3 status separately.

Physics design of the in-vessel collection optics for the ITER electron cyclotron emission diagnostic

Measurement of the electron cyclotron emission (ECE) is one of the primary diagnostics for electron temperature in ITER. In-vessel, in-vacuum, and quasi-optical antennas capture sufficient ECE to achieve large signal to noise with microsecond temporal resolution and high spatial resolution while maintaining polarization fidelity. Two similar systems are required. One views the plasma radially. The other is an oblique view. Both views can be used to measure the electron temperature, while the oblique is also sensitive to non-thermal distortion in the bulk electron distribution. The in-vacuum optics for both systems are subject to degradation as they have a direct view of the ITER plasma and will not be accessible for cleaning or replacement for extended periods. Blackbody radiation sources are provided for in situ calibration.

Preliminary measurements of the edge magnetic field pitch from 2-D Doppler backscattering in MAST and NSTX-U (invited)

The Synthetic Aperture Microwave Imaging (SAMI) system is a novel diagnostic consisting of an array of 8 independently phased antennas. At any one time, SAMI operates at one of the 16 frequencies in the range 10-34.5 GHz. The imaging beam is steered in software post-shot to create a picture of the entire emission surface. In SAMI's active probing mode of operation, the plasma edge is illuminated with a monochromatic source and SAMI reconstructs an image of the Doppler back-scattered (DBS) signal. By assuming that density fluctuations are extended along magnetic field lines, and knowing that the strongest back-scattered signals are directed perpendicular to the density fluctuations, SAMI's 2-D DBS imaging capability can be used to measure the pitch of the edge magnetic field. In this paper, we present preliminary pitch angle measurements obtained by SAMI on the Mega Amp Spherical Tokamak (MAST) at Culham Centre for Fusion Energy and on the National Spherical Torus Experiment Upgrade at Princeton Plasma Physics Laboratory. The results demonstrate encouraging agreement between SAMI and other independent measurements.

Modifications to the synthetic aperture microwave imaging diagnostic

The synthetic aperture microwave imaging diagnostic has been operating on the MAST experiment since 2011. It has provided the first 2D images of B-X-O mode conversion windows and showed the feasibility of conducting 2D Doppler back-scattering experiments. The diagnostic heavily relies on field programmable gate arrays to conduct its work. Recent successes and newly gained experience with the diagnostic have led us to modify it. The enhancements will enable pitch angle profile measurements, O and X mode separation, and the continuous acquisition of 2D DBS data. The diagnostic has also been installed on the NSTX-U and is acquiring data since May 2016.

An Approach to Optimise Therapeutic Vancomycin Dosage in a Haemodialysis Population

Haemodialysis patients are at risk of gram-positive bacteraemia and commonly require intravenous vancomycin. Intravenously administered vancomycin is primarily excreted by the kidney and exhibits complex pharmacokinetics in haemodialysis patients; achieving therapeutic levels can be challenging. An audit in our unit showed current practises of vancomycin administration resulted in a high proportion of sub-therapeutic levels. A new protocol was developed with fixed weight-based loading and subsequent dosing guided by pre-dialysis levels, target levels were 10-20mg/L. Its effectiveness was prospectively evaluated between 24th September 2012, and 8th February 2013. During this period 25 patients commenced vancomycin, 15 were included. In total, 112 vancomycin levels were taken, 94 (84%) were therapeutic, this was a significant improvement compared to previous practise (odds ratio 5.4, CI 3.1-9.4, p<0.0001). In conclusion, our study shows this protocol can consistently and reliably achieve therapeutic vancomycin levels.

Readmissions - can they be predicted on admission?

This paper looks at the development of logistic regression models to predict readmissions for medical patients on their initial admission to hospital. The design of our study was a retrospective analysis of a large dataset drawn from a range of secondary sources - medical, nursing, therapy and social care records. Three northern hospitals and related community health districts and social care organizations in the UK participated. Records of 1,192 patients discharged from medical wards during the period April 1992-March 1995 were analysed. Readmission within six weeks of discharge was the main outcome measure.Four logistic regression equations were produced. Three individual site equations were calculated and classification levels for readmission of 17-22 per cent were achieved. Component factors that differed in importance were age, GP contact, social services contact, marital status and living status. The weakest equation was the equation that encompassed patients from all three sites, which classified 7 per cent of readmissions. It is possible to develop equations that will explain readmission for a fifth of medical patients on admission to individual hospitals. Further exploratory work needs to be undertaken to explore reasons for differences between districts and develop more generalizable predictive equations.

New resources for genetic studies in Populus nigra: genome-wide SNP discovery and development of a 12k Infinium array

Whole genome resequencing of 51 Populus nigra (L.) individuals from across Western Europe was performed using Illumina platforms. A total number of 1 878 727 SNPs distributed along the P. nigra reference sequence were identified. The SNP calling accuracy was validated with Sanger sequencing. SNPs were selected within 14 previously identified QTL regions, 2916 expressional candidate genes related to rust resistance, wood properties, water-use efficiency and bud phenology and 1732 genes randomly spread across the genome. Over 10 000 SNPs were selected for the construction of a 12k Infinium Bead-Chip array dedicated to association mapping. The SNP genotyping assay was performed with 888 P. nigra individuals. The genotyping success rate was 91%. Our high success rate was due to the discovery panel design and the stringent parameters applied for SNP calling and selection. In the same set of P. nigra genotypes, linkage disequilibrium throughout the genome decayed on average within 5-7 kb to half of its maximum value. As an application test, ADMIXTURE analysis was performed with a selection of 600 SNPs spread throughout the genome and 706 individuals collected along 12 river basins. The admixture pattern was consistent with genetic diversity revealed by neutral markers and the geographical distribution of the populations. These newly developed SNP resources and genotyping array provide a valuable tool for population genetic studies and identification of QTLs through natural-population based genetic association studies in P. nigra.

Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial

BACKGROUND

Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS.

DESIGN

A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome.

DISCUSSION

The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction.

TRIAL REGISTRATION

Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014).