Reducing Medication Risks in Older Adult Drinkers

Objectives: Prevalent concomitant alcohol and medication use among older adults is placing this group at risk for adverse health events. Given limited existing interventions to address concomitant alcohol and medication risk (AMR), a brief educational intervention was demonstrated. The purpose of the current study was to examine change in AMR behaviors 3 months post-education among older adult drinkers. Methods: A convenience sample of 58 older adult drinkers (mean age = 72) was recruited and followed (n = 40; 70% at follow-up), from four pharmacies in rural Virginia. Results: Findings indicated decreased alcohol consumption in high-risk drinkers. Conclusion: Future research should explore methods to sustain reduced AMR.

Antibody Persistence at the Population Level 5 Years After Mass Vaccination With Meningococcal Serogroup A Conjugate Vaccine (PsA-TT) in Burkina Faso: Need for a Booster Campaign?

Background

In Burkina Faso, serogroup A meningococcal (NmA) conjugate vaccine (PsA-TT, MenAfriVac) was introduced through a mass campaign in children and adults in December 2010. Similar to a serological survey in 2011, we followed population-level antibody persistence for 5 years after the campaign and estimated time of return to previously-published pre-vaccination levels.

Methods

We conducted 2 cross-sectional surveys in 2013 and early 2016, including representative samples (N = 600) of the general population of Bobo-Dioulasso, Burkina Faso. Serum bactericidal antibody titers (rabbit complement) were measured against NmA reference strain F8236 (SBA-ref), NmA strain 3125 (SBA-3125), and NmA-specific immunoglobulin G (IgG) concentrations.

Results

During the 2016 survey, in different age groups between 6 and 29 years, the relative changes in geometric means compared to 2011 values were greater among younger age groups. They were between -87% and -43% for SBA-ref; -99% and -78% for SBA-3125; and -89% and -63% for IgG. In linear extrapolation of age-specific geometric means from 2013 to 2016, among children aged 1-4 years at the time of the PsA-TT campaign, a return to pre-vaccination levels should be expected after 12, 8, and 6 years, respectively, according to SBA-ref, SBA-3125, and IgG. Among older individuals, complete return to baseline is expected at the earliest after 11 years (SBA-ref and SBA-3125) or 9 years (IgG).

Conclusions

Based on SBA-3125, a booster campaign after 8 years would be required to sustain direct immune protection for children aged 1-4 years during the PsA-TT campaign. Antibodies persisted longer in older age groups.

Evaluation of the Effect of Chronic 94 GHz Exposure on Gene Expression in the Skin of Hairless Rats In Vivo

Millimeter waves (MMW) are broadband frequencies that have recently been used in several applications in wireless communications, medical devices and nonlethal weapons [i.e., the nonlethal weapon, Active Denial Systems, (ADS) operating at 94-95 GHz, CW]. However, little information is available on their potential effects on humans. These radio-frequencies are absorbed and stopped by the first layer of the skin. In this study, we evaluated the effects of 94 GHz on the gene expression of skin cells. Two rat populations consisting of 17 young animals and 14 adults were subjected to chronic long-term 94 GHz MMW exposure. Each group of animals was divided into exposed and sham subgroups. The two independent exposure experiments were conducted for 5 months with rats exposed 3 h per day for 3 days per week to an incident power density of 10 mW/cm², which corresponded to twice the ICNIRP limit of occupational exposure for humans. At the end of the experiment, skin explants were collected and RNA was extracted. Then, the modifications to the whole gene expression profile were analyzed with a gene expression microarray. Without modification of the animal's temperature, long-term chronic 94 GHz-MMW exposure did not significantly modify the gene expression of the skin on either the young or adult rats.

Combinations of non-invasive indicators to detect dairy cows submitted to high-starch-diet challenge

High-starch diets (HSDs) fed to high-producing ruminants are often responsible for rumen dysfunction and could impair animal health and production. Feeding HSDs are often characterized by transient rumen pH depression, accurate monitoring of which requires costly or invasive methods. Numerous clinical signs can be followed to monitor such diet changes but no specific indicator is able to make a statement at animal level on-farm. The aim of this pilot study was to assess a combination of non-invasive indicators in dairy cows able to monitor a HSD in experimental conditions. A longitudinal study was conducted in 11 primiparous dairy cows fed with two different diets during three successive periods: a 4-week control period (P1) with a low-starch diet (LSD; 13% starch), a 4-week period with an HSD (P2, 35% starch) and a 3-week recovery period (P3) again with the LSD. Animal behaviour was monitored throughout the experiment, and faeces, urine, saliva, milk and blood were sampled simultaneously in each animal at least once a week for analysis. A total of 136 variables were screened by successive statistical approaches including: partial least squares-discriminant analysis, multivariate analysis and mixed-effect models. Finally, 16 indicators were selected as the most representative of a HSD challenge. A generalized linear mixed model analysis was applied to highlight parsimonious combinations of indicators able to identify animals under our experimental conditions. Eighteen models were established and the combination of milk urea nitrogen, blood bicarbonate and feed intake was the best to detect the different periods of the challenge with both 100% of specificity and sensitivity. Other indicators such as the number of drinking acts, fat:protein ratio in milk, urine, and faecal pH, were the most frequently used in the proposed models. Finally, the established models highlight the necessity for animals to have more than 1 week of recovery diet to return to their initial control state after a HSD challenge. This pilot study demonstrates the interest of using combinations of non-invasive indicators to monitor feed changes from a LSD to a HSD to dairy cows in order to improve prevention of rumen dysfunction on-farm. However, the adjustment and robustness of the proposed combinations of indicators need to be challenged using a greater number of animals as well as different acidogenic conditions before being applied on-farm.

Twelve-month outcomes of MAKINGtheLINK: A cluster randomized controlled trial of a school-based program to facilitate help-seeking for substance use and mental health problems

BACKGROUND

Young people experiencing mental health problems are often reluctant to seek help, particularly from professionals (i.e., doctors or mental health workers). MAKINGtheLINK is a school-based intervention that aims to help adolescents overcome barriers to seeking professional help for mental health and substance use problems.

METHODS

A cluster randomised controlled trial was conducted to evaluate the 12-month outcomes of MAKINGtheLINK among 2447 participants (Mean age=14.9 years, SD=0.5 years, 50% male). Randomisation resulted in 1130 students from 11 schools allocated to receive the intervention, and 1317 students from 10 schools allocated to the wait-list control group. After the baseline assessment, follow-ups were conducted at 6-weeks (n = 2045), 6-months (n = 1874), and 12-months (n = 1827). The primary outcome measure was help-seeking behaviour, from both formal (e.g., health professionals) and informal (e.g., friends, family members) sources. The trial was registered with the Australia and New Zealand Clinical Trials Register (ANZCTR) on the 27th of February 2013 (registration number ACTRN12613000235707).

FINDINGS

The intervention was not associated with overall help-seeking at the 12-month follow-up (p = 0.99, odds ratio [OR]=1.00, 95% CI for OR = 0.70-1.42), or help-seeking for depression (p = 0.28, OR = 1.21, 95%CI =0.86-1.69), stress and anxiety (p = 0.73, OR = 1.04, 95%CI = 0.74-1.47), or alcohol/other drugs (p = 0.84, OR=1.12, CI=0.37-3.37). However, the intervention was associated with increased help-seeking from formal sources (compared to informal sources) both overall (p = 0.005, OR = 1.81, 95%CI = 1.19-2.75), as well as for depression (p = 0.01, OR=2.09, 95%CI=1.19-3.67), and stress and anxiety (p < 0.006, OR = 1.72, 95%CI = 1.17-2.54).

INTERPRETATION

Rates of help-seeking remained unchanged following the intervention. However, MAKINGtheLINK effectively improved the quality of adolescent help-seeking behaviour by increasing help-seeking from formal sources. As prompt treatment is essential in reducing the long-term impact of early onset mental health problems, MAKINGtheLINK has the potential to make a significant contribution to existing early intervention and prevention efforts.

FUNDING

National Health and Medical Research Council (APP1047492).

Does sex predict quality of life after acute coronary syndromes: an Australian, state-wide, multicentre prospective cohort study

OBJECTIVE

Women have reported higher mortality and major adverse cardiovascular events (MACE) following acute coronary syndromes (ACSs) compared with men. With this in mind, we aimed to identify predictors of poor quality of life (QoL) post-ACS as our primary outcome. We examined predictors of MACE, major cerebrovascular events and major bleeding as our secondary outcome.

DESIGN

Prospective cohort study.

SETTING

30 metropolitan centres across the Victorian Cardiac Outcomes Registry network.

PARTICIPANTS

16 517 patients treated with percutaneous coronary intervention (PCI) for ACS (22.9% females). Selection/inclusion criteria: consecutive patients with successful or attempted PCI for ACS from 2013 to 2016, alive at 30 days post-PCI.

EXCLUSION CRITERIA

patients not fulfilling ACS criteria. At 30 days, 2497 (64.7% females) completed the QoL EQ-5D-3L instrument.

PRIMARY AND SECONDARY OUTCOME MEASURES

QoL, assessed using the EuroQo-5Dimensions (EQ-5D-3L) instrument by telephone at 30 days. Independent predictors of QoL were identified by univariate and multivariate logistic regression analyses.

RESULTS

Women were significantly older with more diabetes, cerebrovascular disease and renal failure. Regarding the primary outcome, female sex was independently associated with moderate/severe impairment in all EQ-5D-3L domains including mobility (OR 2.38, 95% CI 2.06 to 2.75, p<0.001), personal care (OR 2.14, 95% CI 1.73 to 2.66, p<0.001), activities of daily living (OR 1.84, 95% CI 1.63 to 2.08, p<0.001), pain/discomfort (OR 1.44, 95% CI 1.24 to 1.67, p<0.001) and anxiety/depression (OR 1.49, 95% CI 1.30 to 1.70, p<0.001). Women had significantly lower self-rated Visual Analogue Scale scores (80.0 for both groups, IQR 60-85 vs 70-90, p<0.001). There was no significant difference between the sexes in secondary outcomes.

CONCLUSIONS

Female sex was a predictor of poorer QoL following PCI for ACS including significantly higher pain, anxiety and depression. This was independent of age, comorbidities and ACS presentation. There is a clinical need for a tailored approach in female ACS management, for example, emphasis on management of depressive and anxiety symptoms.

A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital

Background

Acinetobacter baumannii causes frequently nosocomial infections worldwide. Its ability to survive on dry surfaces facilitates its spread and the persistence of endemic situations, especially in the intensive care units (ICUs).

The objective of this paper is to describe a multicomponent intervention program designed to control a hyperendemic persistence of multidrug-resistant A. baumannii (MDR-Ab) and to characterize its impact.

Methods

Design: Quasi-experimental intervention study based on open cohorts.

Setting: Public tertiary referral centre. Period: January 2009–August 2017.

Intervention: multifaceted program based on environmental decontamination, hand hygiene, antimicrobial stewardship, contact precautions, active surveillance, weekly reports and regular meetings.

Analysis: joinpoint regression and interrupted time-series analysis.

Results

The intervention was successfully implemented. Through the study period, the compliance with contact precautions changed from 0 to 100% and with hand hygiene, from 41.8 to 82.3%. Between 2012 and 2016, the antibiotic consumption decreased from 165.35 in to 150.44 daily-defined doses/1000 patients-days in the ICU. The incidence density of MDR-Ab in the ICU was 10.9 cases/1000 patients-days at the beginning of the intervention. After this moment, the evolution of the incidence density of MDR-Ab was: between months 0 and 6°, it remained stable; between months 7° and 10°: there was an intense decrease, with an average monthly percentage change (AMPC) = − 30.05%; from 11° month until the end, the decrease was lighter but continuous (AMPC:-2.77%), achieving an incidence density of 0 cases/1000 patients-days on the 18° month, without any new case for 12 months. From the 30° month until the end of the study period, several little outbreaks of MDR-Ab were detected, all of them rapidly controlled. The strains of MDR-Ab isolated during these outbreaks were not clonally related with the previously endemic one, which supports its eradication from the environmental reservoirs.

Conclusion

The multicomponent intervention performed by a multidisciplinary team was effective to eradicate the endemic MDR-Ab.

Reactivation of Plasmodium infection during a treatment with infliximab: A case report

We describe a symptomatic Plasmodium falciparum infection in a 29-year-old Guinean man receiving Infliximab for one year and without recent travel. The reactivation of submicroscopic malaria following the inhibition of TNF-alpha by infliximab is suspected.

Use of P-values and the terms "significant", "non-significant" and "suggestive" in Abstracts in the European Annals of Otorhinolaryngology, Head & Neck Diseases

OBJECTIVES

To evaluate the use of P-values and the terms "significant", "non-significant" and "suggestive" in Abstracts in the European Annals of Otorhinolaryngology, Head & Neck Diseases.

MATERIALS AND METHODS

Consecutive articles accepted for publication during the period January 2016 - February 2019 were systematically reviewed. Main goal: descriptive analysis of the citation of P-values and use of the terms "significant", "non-significant" and "suggestive" in Abstracts. Secondary goal: analytic study of: (i) correlations between citation of a P-value and the main characteristics of authors and topics; and (ii) misuse of the terms "significant", "non-significant" and "suggestive" with respect to cited P-values, and correlations with author and topic characteristics.

RESULTS

In all, 91 articles were included. P-values and the terms "significant", "non-significant" and "suggestive" were cited in 35.1%, 41.7%, 10.9% and 0% of Abstracts, respectively. Citing a P-value did not significantly correlate with author or topic characteristics. There were discrepancies between the terms "non-significant", "significant" and "suggestive" and P-values given in the body of the article in 57.1% of Abstracts, with 30.7% overestimation and 25.2% underestimation of results, without significant correlation with author or topic characteristics.

CONCLUSION

Authors, editors and reviewers must pay particular attention to the spin resulting from inappropriate use of the terms "significant", "non-significant" and "suggestive" in Abstracts of articles submitted to the European Annals of Otorhinolaryngology, Head & Neck Diseases, to improve the rigor, quality and value of the scientific message delivered to the reader.

Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.

Association of Obesity With Septic Complications After Major Abdominal Surgery: A Secondary Analysis of the RELIEF Randomized Clinical Trial

IMPORTANCE

Body mass index (BMI) has been the most common obesity measure to assess perioperative risk; however, cardiometabolic risk is associated with the burden of visceral fat. Definitive evidence on the association of visceral fat measures, such as waist circumference and waist-to-hip ratio (WHR), with postoperative complications is lacking.

OBJECTIVE

To compare the value of waist circumference with the value WHR and BMI in predicting adverse outcomes, including major septic complications and persistent disability, following major abdominal surgery.

DESIGN, SETTING, AND PARTICIPANTS

This planned secondary analysis of the Restrictive vs Liberal Fluid Therapy for Major Abdominal Surgery (RELIEF) randomized clinical trial took place at 47 centers in 7 countries between October 2013 and September 2016, with 90-day follow-up. A total of 2954 adult RELIEF participants were coenrolled in this secondary analysis. Data analysis took place from December 2018 to September 2019.

EXPOSURES

Waist circumference, WHR, and BMI measurements.

MAIN OUTCOMES AND MEASURES

The primary outcomes were 30-day major septic complications and 90-day persistent disability or death.

RESULTS

Of 2954 eligible participants, 2755 were included (mean [SD] age, 65.9 [12.9] years; 1426 [51.8%] men) in the final analysis. A total of 564 participants (20.6%) experienced at least 1 major septic complication within 30 days after surgery (sepsis, 265 [9.7%]; surgical site infection, 409 [14.9%]; anastomotic leak, 78 [2.8%]; pneumonia, 104 [3.8%]). Waist circumference had a statistically significantly larger odds ratio (OR) and discrimination indices as well as a smaller prediction error than WHR or BMI for 30-day major septic complications or death (waist circumference: OR, 1.44; 95% CI, 1.28-1.62; P < .001; area under the receiver operating characteristic curve, 0.641; net reclassification index, 0.266; integrated discrimination improvement [score × 104], 152.98; Brier score, 0.162; WHR: OR, 1.15; 95% CI, 1.03-1.28; P = .01; area under the receiver operating characteristic curve, 0.621; net classification index, 0.199; integrated discrimination improvement [score × 104], 28.47; Brier score, 0.164; BMI: OR, 1.33; 95% CI, 1.17-1.50; P < .001; area under the receiver operating characteristic curve, 0.629; net reclassification index, 0.205; integrated discrimination improvement [score × 104], 85.61; Brier score, 0.163) but not for any other outcomes.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of the RELIEF randomized clinical trial, waist circumference was observed to be superior to other adiposity indices in predicting 30-day major septic complications alone or in conjunction with death following elective major abdominal surgery. Findings suggest that waist circumference is a useful adiposity measure that should be incorporated in preoperative risk assessment for such complications.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01424150.

Complete upper airway collapse and apnoea during tethered swimming in horses

BACKGROUND

There is limited knowledge of the breathing strategy and impact on the patency of the upper respiratory tract (URT) in swimming horses.

OBJECTIVES

To describe the respiratory responses and endoscopic appearance of the URT during tethered swimming in horses.

STUDY DESIGN

Prospective descriptive study.

METHODS

Ten race-fit horses, with no history of URT obstruction, were examined during tethered swimming. Endoscopic examination, heart rate, sound recordings and above and below water video recordings were obtained. Plasma lactate concentration was measured before and 5 min after swimming and tracheal endoscopy was performed 30 min after exercise to assess for presence of blood or mucus. Four horses also underwent endoscopy during exercise on the track.

RESULTS

Mean (±s.d.) breathing frequency was 28 ± 5 breaths/min during swimming, with a brief inspiration (mean ± s.d. T_I  = 0.51 ± 0.08 s), followed by a period of apnoea (1.59 ± 0.53 s) and then a short, forced expiration (T_E  = 0.42 ± 0.5 s). During apnoea all horses exhibited complete collapse of the URT including closure of the external nares, nasopharynx and rima glottidis (with bilateral adduction of the arytenoid cartilages and vocal folds) and, in two horses, epiglottic retroversion. No horses had URT collapse during overground exercise. Locomotor-respiratory coupling was not observed during swimming. Median (IQR) plasma lactate post swim was 4.71 mmol/L (2.08-8.09 mmol/L) vs 0.68 mmol/L (0.65-0.71 mmol/L) preswim. Post swim endoscopy revealed grade 1 exercise-induced pulmonary haemorrhage (EIPH) in 2 horses. Median mucus grade was 1 (range 0-3).

MAIN LIMITATIONS

Overground endoscopy was not performed in all horses.

CONCLUSIONS

Horses experienced complete URT collapse associated with post inspiratory apnoea when swimming. The reason for this is unknown but may be to aid buoyancy or associated with the mammalian dive response - a survival reflex to preserve oxygen stores and prevent water entering the lungs.

Comparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients Aged >90 Years Versus <90 Years

Limited data exist regarding transcatheter aortic valve implantation (TAVI) in nonagenarians. This study evaluates the short- and mid-term outcomes of nonagenarians after TAVI. Between 2008 and 2017, all patients who underwent TAVI in 2 centers in Australia were prospectively included in a registry and followed-up for 5 years. Outcomes were based on VARC-2 criteria. Additionally, the patient's reliance on daily living support at 1 year was evaluated. Of the 588 patients, 71 (12.1%) were ≥90 years old (mean age 92.2 ± 2 vs 83.2 ± 6 years in <90-year-old patients), with a median STS-PROM score of 5.7 (vs 3.9 in <90-year-old patients, odds ratio [OR] 1.07, 95% confidence interval 1.01 to 1.13, p = 0.02) and a median clinical frailty score of 4 (vs 4 <90-year-old patients, OR 0.88, p = 0.44). Mortality was 0% in ≥90-year-old patients at 30 days (vs 1.4% in <90-year-old patients; p = 0.82) and 12% at 1 year (vs 7.4%, in <90-year-old patients; hazard ratio 1.64, p = 0.20). There were no significant differences in periprocedural complications and mortality at 5 years between the 2 groups. At 1 year, nonagenarians were significantly more likely to live in an aged-care facility compared with <90-year-old patients (25% vs 16%, OR 5.99, 95% confidence interval 2.62 to 13.67, p <0.001). In conclusion, carefully selected nonagenarians have excellent short- and mid-term outcomes post-TAVI and should therefore not be refused based on age alone. Nevertheless, the significantly higher rate of transfer to an aged-care facility highlights the importance of a more refined frailty assessment before TAVI than the currently widely used clinical frailty score.

Sex Differences in Electrophysiology, Ventricular Tachyarrhythmia, Cardiac Arrest and Sudden Cardiac Death Following Acute Myocardial Infarction

BACKGROUND

Women experience less appropriate implantable cardioverter-defibrillator (ICD) interventions and are underrepresented in randomised ICD trials. Sex-differences in inducible and spontaneous ventricular tachycardia/fibrillation (VT/VF), cardiac arrest and sudden cardiac death (SCD) early post-myocardial infarction (MI) require further study.

METHODS

Consecutive ST-elevation MI patients with left ventricular ejection fraction (LVEF)≤40% underwent electrophysiology study (EPS) to target early prevention of SCD. An ICD was implanted for a positive (inducible monomorphic VT) but not a negative (no arrhythmia or inducible VF) EPS. The combined primary endpoint of VT/VF (spontaneous or ICD-treated), cardiac arrest or SCD was assessed using competing risk survival analysis in women versus men with adjustment for confounders. Logistic regression was used to determine independent predictors of inducible VT at EPS.

RESULTS

A total of 403 patients (16.9% female) underwent EPS. Women were significantly older than men but with similar LVEF (31.5 ± 6.3 versus 31.6 ± 6.4%, p = 0.91). Electrophysiology study was positive for inducible VT in 22.1% and 33.4% (p = 0.066) and an ICD implanted in 25.0% and 33.4% (p = 0.356) of women versus men. Appropriate ICD activations (VT/VF) occurred in 5.9% of women and 36.6% of men (p = 0.012). The adjusted cumulative primary endpoint incidence was significantly lower in women than men (1.6% versus 26.5%, p = 0.03). Female sex was not an independent predictor of inducible VT at EPS (HR 0.63, 95% CI 0.33-1.23, p = 0.178).

CONCLUSIONS

Women with early post-MI cardiomyopathy had lower VT/VF, cardiac arrest and SCD, compared to men. In ICD recipients the rate of appropriate activations was six-fold less in women compared to men.

Health and Care Related Risk Factors for Suicide Among Nursing Home Residents: A Data Linkage Study

This study aimed to examine associations between health status and care needs of nursing home residents and risk of death from suicide compared to other causes through a retrospective data linkage cohort study examining nursing home resident deaths in Australia between 2000 and 2013. Data linkage was performed between aged care assessment tools-Resident Classification System and Aged Care Funding Instrument-and the National Coronial Information System. A competing risks survival analysis was performed to determine the association between care assessment variables (activities of daily living (ADL), behavior, and complex health care) and the risk of death from suicide and any other cause. Of the 146 nursing home residents who died from suicide, 130 (89%) were matched to their assessment data, with comparable information available for 95 residents (65%). Residents who required high levels of care with ADL, physical health care, and cognitive and behavioral issues had a higher risk of dying from all other causes, yet lower risk of dying from suicide. The study findings demonstrate the feasibility and value of linking these two data sets; highlight a need for improved data collection processes; and support a person-centered care approach for prevention of suicide among nursing home residents.

Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Australia: a protocol for a retrospective observational study

INTRODUCTION AND AIMS

Extramedical use of, and associated harms with pharmaceutical opioids are common. Analysis of coded ambulance clinical records provides a unique opportunity to examine a national population-level indicator of relative harms. This protocol describes an observational study with three aims: (1) to compare supply adjusted rates of pharmaceutical opioid-related ambulance attendances for buprenorphine, codeine, fentanyl, oxycodone, oxycodone-naloxone, morphine, pethidine, tramadol and tapentadol; (2) to compare presentation characteristics for these commonly used pharmaceutical opioids and (3) to describe the context surrounding ambulance presentations related to oxycodone, a widely used opioid with an established abuse liability, and tapentadol, a more recent 'atypical' opioid on the Australian market, with fewer studies that have directly examined signals of extramedical use.

METHOD

Trained coders extract data from clinical records for ambulance presentations relating to extramedical use of commonly used pharmaceutical opioids. These data form the basis of a large, national database that captures alcohol-related and drug-related harms. Supply adjusted rates of presentations will be examined using Poisson regression. Multinomial logistic regression will be used to compare severity and other characteristics of attendances relating to different pharmaceutical opioids. Tapentadol-related and oxycodone-related cases will be qualitatively examined to understand the situationally specific contexts of the ambulance attendances outside of the characteristics captured in routinely coded variables.

ETHICS AND DISSEMINATION

Ethics approval related to analysis of ambulance attendance data was obtained from the Eastern Health Human Research Ethics Committee (E122 08-09), with an amendment specific to the qualitative analysis. Findings will be submitted for peer review in 2019. The understanding of risk profiles in real-world settings is of international public health importance. The analysis and publication of findings from this national dataset of clinical records will provide one of the most nuanced analyses to date of relative harms across nine pharmaceutical opioids over a 6-year period.

Communication apprehension mediates the effects of past experience discussing substance use on child and adolescent psychiatrists' self-efficacy

Objective Child and Adolescent Psychiatrists (CAPs) treat patients who are at an increased risk of developing a substance use disorder in their lifetime. However, CAPs often experience apprehension when it comes to discussing substance use with their patients, and this apprehension may come from past experiences when these discussions have gone poorly. This study seeks to understand whether or not apprehension moderates the relationship between past experiences and self-efficacy for CAPs when discussing substance use with their patients. Methods This study used a national online survey of CAPs (n = 170) to test the extent to which apprehension mediated the relationship between past experiences discussing substance use and self-efficacy to do so. Results The results showed that past experience affects self-efficacy and apprehension serves as a mediator of this relationship. Conclusion This study helps to shed light on the determinants that influence providers' perceptions of self-efficacy. Understanding what factors affect self-efficacy is important because these factors can then be targeted through training. Practice implications Patient-provider communication skills training for CAPs should happen early in their education so that they are less likely to become apprehensive about discussing substance use with their patients.

Effect of increasing the proportion of chicory in forage-based diets on intake and digestion by sheep

There is a lot of evidence that chicory could be a highly palatable and nutritious source of forage for ruminants, well adapted to climate change and dry conditions in summer, thanks to its resistance to drought and high water content. This study aimed to describe the effect of incorporating chicory to ryegrass or to a ryegrass-white clover mixture on feeding behaviour, digestive parameters, nitrogen (N) balance and methane (CH4) emissions in sheep. In total, three swards of ryegrass, white clover and chicory were established and managed in a manner ensuring the forage use at a constant vegetative stage throughout the experiment. In all, four dietary treatments (pure ryegrass; binary mixture: 50% ryegrass-50% chicory; ternary mixture: 50% ryegrass-25% white clover-25% chicory; and pure chicory) were evaluated in a 4×4 replicated Latin square design with eight young castrated Texel sheep. Each experimental period consisted of an 8-day diet adaptation phase, followed by a 6-day measuring phase during which intake dynamics, chewing activity, digestibility, rumen liquid passage rate, fermentation end-products, N balance and CH4 emissions were determined. Data were analysed using a mixed model and orthogonal contrasts were used to detect the potential associative effects between ryegrass and chicory. The daily voluntary dry matter intake was lower for pure ryegrass than for diets containing chicory (P<0.001) and increased quadratically from 1.39 to 1.74 kg/day with increasing proportion of chicory. Huge positive quadratic effects (P<0.001) between ryegrass and chicory were detected on eating time and eating rate just after feeding indicating an increase of the motivation to eat with mixtures, whereas rumination activity decreased linearly with the proportion of chicory (P<0.001). The organic matter digestibility was similar among treatments (around 80%), but a strong positive quadratic P<0.001) effect was observed on liquid passage rate suggesting that chicory allowed fast particle breakdown in the rumen. Animals fed with the ryegrass-white clover-chicory mixture had the higher urinary N losses (P<0.001), whereas retained N per day or per g N intake was greater when the proportion of chicory was at least 50% (P<0.001) being ~40% greater than for the other treatments. The CH4 yield was lower with pure chicory than with the other treatments (P<0.001) for which emissions were similar. In conclusion, mixing ryegrass and chicory in equal proportions produces a synergy on voluntary intake and an improved N use efficiency likely due to complementarity in chemical composition, increased motivation to eat and faster ruminal particle breakdown.