Rates of emergency department visits attributable to alcohol use in Ontario from 2003 to 2016: a retrospective population-level study

The association between off- and on-premise alcohol outlet density and 100% alcohol-attributable emergency department visits by neighbourhood-level socioeconomic status in Ontario, Canada

Alcohol availability is positively associated with alcohol use and harms, but the influence of socioeconomic status (SES) on these associations is not well established. This population-based cross-sectional study examined neighbourhood-level associations between physical alcohol availability (measured as off- and on-premise alcohol outlet density) and 100% alcohol-attributable emergency department (ED) visits by neighbourhood SES in Ontario, Canada from 2017 to 2019 (n = 19,740). A Bayesian spatial modelling approach was used to assess associations and account for spatial autocorrelation, which produced risk ratios (RRs) and 95% credible intervals (95% CrI). Each additional off-premise alcohol outlet in a neighbourhood was associated with a 3% increased risk of alcohol-attributable ED visits in both men (RR = 1.03, 95%CrI: 1.02-1.04) and women (RR = 1.03, 95% CrI: 1.02-1.04). Positive associations were also observed between on-premise alcohol outlet density and alcohol-attributable ED visits, although effect sizes were small. A disproportionately greater association with ED visits was observed with increasing alcohol outlet density in the lowest compared to higher SES neighbourhoods. Reducing physical alcohol availability may be an important policy lever for reducing alcohol harm and alcohol-attributable health inequities.

The association between alcohol retail access and health care visits attributable to alcohol for individuals with and without a history of alcohol-related health-care use

BACKGROUND AND AIMS

Alcohol retail access is associated with alcohol use and related harms. This study measured whether this association differs for people with and without heavy and disordered patterns of alcohol use.

DESIGN

The study used a repeated cross-sectional analysis of health administrative databases.

SETTING, PARTICIPANTS/CASES

All residents of Ontario, Canada aged 10-105 years with universal health coverage (n = 10 677 604 in 2013) were included in the analysis.

MEASUREMENTS

Quarterly rates of emergency department (ED) and outpatient visits attributable to alcohol in 464 geographic regions between 2013 and 2019 were measured. Quarterly off-premises alcohol retail access scores were calculated (average drive to the closest seven stores) for each geographic region. Mixed-effect linear regression models adjusted for area-level socio-demographic covariates were used to examine associations between deciles of alcohol retail access and health-care visits attributable to alcohol. Stratified analyses were run for individuals with and without prior alcohol-attributable health-care use in the past 2 years.

FINDINGS

We included 437 707 ED visits and 505 271 outpatient visits attributable to alcohol. After adjustment, rates of ED visits were 39% higher [rate ratio (RR) = 1.39, 95% confidence interval (CI) = 1.20-1.61] and rates of outpatient visits were 49% higher (RR = 1.49, 95% CI = 1.26-1.75) in the highest versus lowest decile of alcohol access. There was a positive association between alcohol access and outpatient visits attributable to alcohol for individuals without prior health-care attributable to alcohol (RR = 1.65, 95% CI = 1.39-1.95 for the highest to lowest decile of alcohol access) but not for individuals with prior health-care attributable to alcohol (RR = 1.08, 95% CI = 0.90-1.30). There was a positive association between alcohol access and ED visits attributable to alcohol for individuals with and without prior health-care for alcohol for ED visits.

CONCLUSION

In Ontario, Canada, greater alcohol retail access appears to be associated with higher rates of emergency department (ED) and outpatient health-care visits attributable to alcohol. Individuals without prior health-care for alcohol may be more susceptible to greater alcohol retail access for outpatient but not ED visits attributable to alcohol.

Socio-economic inequities in emergency department visits for wholly alcohol-attributable acute and chronic harms in Canada, 2003-2017

INTRODUCTION

Individuals with low socio-economic position (SEP) experience disproportionate alcohol-attributable harm. Limited research has investigated whether these inequities are driven by alcohol-attributable conditions that are acute or chronic. The study aimed to estimate the sex-specific associations between SEP and incident wholly alcohol-attributable emergency department (ED) visits for acute and chronic harms, respectively.

METHODS

A cohort study was conducted using the Canadian Community Health Survey (2003-2008) linked to the National Ambulatory Care Reporting System (2002-2017) in Alberta and Ontario. SEP was measured using educational attainment. Acute and chronic ED visits were captured in the National Ambulatory Care Reporting System follow-up data. Hazard models were fit to estimate the association between SEP and acute and chronic wholly alcohol-attributable ED visits.

RESULTS

The analytical sample included 88,865 respondents. In men and women, individuals with lower SEP had increased hazard of acute ED visits (women hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.07-2.87; men HR 3.47, 95% CI 2.29-5.25) and chronic ED visits (women HR 2.24, 95% CI 1.04-4.80; men HR 5.02, 95% CI 2.88-8.75). Acute and chronic wholly alcohol-attributable ED visit rates were higher in men than women.

DISCUSSION AND CONCLUSIONS

The findings indicated lower SEP was associated with greater harms for both acute and chronic wholly alcohol-attributable ED visits when compared to their higher SEP counterparts. We conclude that gradients in SEP are associated with acute and chronic harms. These results highlight a need for equitable interventions that reduce the absolute burden of inequities in both acute and chronic wholly alcohol-attributable ED visits.

SAEM GRACE: Anti-craving medications for alcohol use disorder treatment in the emergency department: A systematic review of direct evidence

OBJECTIVES

Alcohol-related concerns commonly present to the emergency department (ED), with a subset of individuals experiencing the symptoms of an alcohol use disorder (AUD). As such, examining the efficacy of pharmacological anti-craving treatment for AUD in the ED is of increasing interest. The objective of this systematic review was to evaluate the direct evidence assessing the efficacy of providing anti-craving medications for AUD treatment in the ED.

METHODS

A systematic search was conducted according to the patient-intervention-control-outcome question: (P) adults (≥18 years old) presenting to the ED with an AUD (including suspected AUD); (I) anti-craving medications (i.e., naltrexone, acamprosate, gabapentin); (C) no prescription or placebo; (O) reduction of repeat ED visits, engagement in addiction services, reductions in heavy drinking days, reductions in any drinking and amount consumed (or abstinence), and in relapse. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies.

RESULTS

From 143 potentially relevant articles, 6 met inclusion criteria: 3 clinical trials, and 3 case studies. The clinical trials identified evaluated oral versus extended-release naltrexone, monthly extended-release naltrexone injections, and disulfiram. Both oral and extended-release naltrexone resulted in decreased alcohol consumption. Monthly extended-release naltrexone injections resulted in significant improvements in drinking and quality of life. Although out of scope, the disulfiram studies identified did not result in an improvement in drinking in comparison to no medication.

CONCLUSIONS

Overall, there are few studies directly examining the efficacy of anti-craving medications for AUD in the ED, although the limited evidence that exists is supportive of naltrexone pharmacotherapy, particularly extended-release injection formulation. Additional randomized controlled trials are necessary for substantive direct evidence on anti-craving medication initiation in the ED.

SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence

OBJECTIVES

Alcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first-line medications for treating AWS but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED.

METHODS

A systematic search was conducted and designed according to the patient-intervention-comparator-outcome (PICO) question: (P) adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) phenobarbital (including adjunctive); (C) benzodiazepines or no intervention; and (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies.

RESULTS

From 70 potentially relevant articles, seven studies met inclusion criteria: three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials (RCTs), one examining phenobarbital monotherapy and one examining adjunctive phenobarbital. Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine-only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis.

CONCLUSIONS

Relatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.

Screening for harmful substance use in emergency departments: a systematic review

BACKGROUND

Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use.

METHODS

We included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results.

RESULTS

Our search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82-85% and specificities 70-77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies' risk of bias were mostly high or uncertain.

CONCLUSIONS

Six screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.

Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol

BACKGROUND AND METHODS

We conducted a population-based, retrospective cohort study of first-time emergency department (ED) visits in adolescents and young adults (AYA) due to alcohol and compared mortality to AYA with nonalcohol ED visits between 2009 and 2015 using standardized all-cause mortality ratios (age, sex, income, and rurality). We described the cause of death for AYA and examined the association between clinical factors and mortality rates in the alcohol cohort using proportional hazard models.

RESULTS

A total of 71,776 AYA had a first-time ED visit due to alcohol (56.1% male, mean age 20.7 years) between 2009 and 2015, representing 3.3% of the 2,166,838 AYA with an ED visit in this time period. At 1 year, there were 2396 deaths, 248 (10.3%) following an ED visit related to alcohol. First-time alcohol ED visits were associated with a threefold higher risk in mortality at 1 year (0.35% vs. 0.10%, adjusted hazard ratio [aHR] 3.07, 95% confidence interval [CI] 2.69-3.51). Mortality was associated with age 25-29 years (aHR 3.88, 95% CI 2.56-5.86), being male (aHR 1.98, 95% CI 1.49-2.62), having a history of mental health or substance use (aHR 3.22, 95% CI 1.64-6.32), cause of visit being withdrawal/dependence (aHR 2.81, 95% CI 1.96-4.02), and having recurrent ED visits (aHR 1.97, 95% CI 1.27-3.05). Trauma (42.7%), followed by poisonings from drugs other than opioids (38.3%), and alcohol (28.6%) were the most common contributing causes of death.

CONCLUSION

Incident ED visits due to alcohol in AYA are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation. These findings may help inform the need and urgency for follow-up care in this population.

Characterizing the clinical subgroups of individuals who present to the emergency department for alcohol-related harms in Ontario, Canada: A latent class analysis

Alcohol-related emergency department (ED) visits are common and associated with adverse clinical outcomes, including premature mortality. This population-based retrospective cohort study identified clinically distinct subgroups of individuals who experience alcohol-related ED visits and characterized differences in the risk of adverse outcomes between them. 73,658 individuals who experienced an alcohol-related ED visit in Ontario, Canada between 2017 and 2018 were identified. Latent class analysis (LCA) revealed five clinically distinct subgroups within the overall cohort. These subgroups followed a severity gradient from low-frequency service use for acute intoxication to high-frequency service use for alcohol use disorder (AUD) and related comorbidities. Relative to those presenting for acute intoxication, those presenting for AUD and comorbidities had a much higher risk of hospital admission (adjusted odds ratio [aOR]: 8.26, 95 % confidence interval [CI]: 7.81-8.75) and post-discharge mortality (adjusted hazard ratio [aHR]: 3.07, 95 % CI: 2.81-3.37). There was a subgroup of individuals with a history of high frequency alcohol-related health service use who were at the highest risk of experiencing another alcohol-related ED visit after the index event (aHR: 4.76, 95 % CI: 4.55-4.99). Individuals who experience alcohol-related ED visits are not a homogenous population, but a constellation of subgroups with different clinical characteristics and risk of adverse outcomes.

Examining gender differences in adolescent exposure to food and beverage marketing through go-along interviews

This study explores how adolescents engage with unhealthy food and beverage marketing in online settings, from a gender perspective. Employing an online ethnography approach and using go-along interviews, we explored the experiences of adolescent boys and girls aged 13-17 as they navigated their online experiences with digital food and beverage marketing. Notable themes emerged, including the identification of predatory actions by food companies, the role of protective factors such as family, and the influence of social media influencers in shaping adolescent dietary preferences. Importantly, this research unearthed gender disparities in the participants' responses. Girls, in particular, exhibited a heightened awareness of the protective role played by their families, emphasized the influence of color in marketing strategies, recognized the significance of gender in marketing, and reported exposure to alcohol advertisements-findings that boys less frequently echoed. The study underscores the importance of adolescence as a critical phase in development, during which food companies target these impressionable individuals, driven by their independence and potential for brand loyalty. Moreover, it highlights the potential avenue of gender-specific marketing, offering valuable insights into the gendered dimensions of adolescents' food marketing experiences. By examining the interplay between digital food marketing and gender, this research addresses a critical gap in the literature, shedding light on how gender influences adolescents' perceptions, responses, and behaviors in the context of food marketing strategies. These findings have the potential to inform adolescents of the marketing techniques that target them and guide policymakers in developing and implementing evidence-based regulations aimed at safeguarding adolescents from exposure to unhealthy food marketing.

"Whatever journey you want to take, I'll support you through": a mixed methods evaluation of a peer worker program in the hospital emergency department

BACKGROUND

People who are unhoused, use substances (drugs and/or alcohol), and who have mental health conditions experience barriers to care access and are frequently confronted with discrimination and stigma in health care settings. The role of Peer Workers in addressing these gaps in a hospital-based context is not well characterized. The aim of this evaluation was to 1) outline the role of Peer Workers in the care of a marginalized populations in the emergency department; 2) characterize the impact of Peer Workers on patient care, and 3) to describe how being employed as a Peer Worker impacts the Peer.

METHODS

Through a concurrent mixed methods evaluation, we explore the role of Peer Workers in the care of marginalized populations in the emergency department at two urban hospitals in Toronto, Ontario Canada. We describe the demographic characteristics of patients (n = 555) and the type of supports provided to patients collected through a survey between February and June 2022. Semi-structured, in-depth interviews were completed with Peer Workers (n = 7). Interviews were thematically analyzed using a deductive approach, complemented by an inductive approach to allow new themes to emerge from the data.

RESULTS

Support provided to patients primarily consisted of friendly conversations (91.4%), discharge planning (59.6%), tactics to help the patient navigate their emotions/mental wellbeing (57.8%) and sharing their lived experience (50.1%). In over one third (38.9%) of all patient interactions, Peer Workers shared new information about the patient with the health care team (e.g., obtaining patient identification). Five major themes emerged from our interviews with Peer Workers which include: (1) Establishing empathy and building trust between the patient and their care team through self-disclosure; (2) Facilitating a person-centered approach to patient care through trauma-informed listening and accessible language; (3) Support for patient preferences on harm reduction; (4) Peer worker role facilitating self-acceptance and self-defined recovery; and (5) Importance of supports and resources to help Peer Workers navigate the emotional intensity of the emergency department.

CONCLUSIONS

The findings add to the literature on Peer Worker programs and how such interventions are designed to best meet the needs of marginalized populations.

Outcomes in Clinical Subgroups of Patients With Alcohol-Related Hospitalizations

Importance

Alcohol-related hospitalizations are common and associated with significant cost to the health care system. We have a limited understanding of the characteristics of individuals who experience alcohol-related hospitalizations, which limits our capacity to prioritize those at the highest risk of postdischarge harm.

Objective

To identify and characterize the clinical subgroups of individuals who are hospitalized for alcohol-related harms.

Design, Setting, and Participants

This cohort study used latent class analysis (LCA) to identify clinical subgroups of individuals experiencing alcohol-related hospitalizations in 2 provinces in Canada. All individuals between ages 10 and 105 years who were hospitalized for an alcohol-related harm between January 2017 and December 2018 (ie, the index hospitalization) were eligible. Data were analyzed between June 2023 and August 2023.

Exposures

The exposure of interest was the clinical subgroup that an individual belonged to. These subgroups were identified using an LCA based on (1) the characteristics of the index hospitalization and (2) the history of alcohol-related health service use.

Main Outcomes and Measures

In-hospital mortality, alcohol-related hospital readmission, and all-cause mortality in the year following discharge from the index hospitalization. The association between subgroup membership and the risk of in-hospital and postdischarge outcomes was evaluated using multivariable regression.

Results

A total of 34 043 individuals were included in analysis, 4753 from Manitoba (median [IQR] age, 49 [40-58] years; 1786 female [37.6%]) and 29 290 from Ontario (median [IQR] age, 57 [45-67] years; 8527 female [29.1%]). Seven subgroups were identified following a gradient from low-frequency service use for acute intoxication to high-frequency service use for severe alcohol use disorder and liver disease. In Ontario, there were 4431 individuals in the liver disease subgroup representing 15.5% of the cohort who were at the highest risk of 1-year mortality (1382 [31.2%]) relative to the acute intoxication subgroup (42 [4.0%]) (adjusted hazard ratio [aHR], 3.83; 95% CI, 2.80-5.24). There was also a small subgroup (10.6%) of individuals with high-frequency alcohol-related health service use who had a much higher hazard of readmission following the index hospitalization (1-year readmission: 703 of 1526 [46.1%] vs 104 of 1058 [9.8%] in the acute intoxication subgroup; aHR, 5.09; 95% CI, 4.11-6.31).

Conclusions and Relevance

In this population-based cohort study of individuals experiencing alcohol-related hospitalizations, we identified several small, clinically distinct subgroups that were at a disproportionately high risk of readmission and mortality. These groups could merit prioritization in strategies aimed at reducing the risk of adverse outcomes following alcohol-related hospitalizations.

Population-Based Repeated Cross-Sectional Study of Hospitalizations for Comorbid Physical and Psychiatric Disorders in Young Adults in Ontario, Canada

PURPOSE

To measure trends in the rates and costs of hospitalizations over a 15-year period among young adults with physical and/or psychiatric disorders.

METHODS

This population-based, repeated cross-sectional study identified all 18- to 26- year-olds hospitalized in Ontario, Canada from April 1, 2003 and March 31, 2018 (fiscal years 2003-2017). Using discharge diagnoses, we assigned hospitalizations to one of four categories: 1) psychiatric disorder only; 2) primary psychiatric disorder with comorbid physical illness; 3) primary physical with comorbid psychiatric disorder; and 4) physical illness only. We compared health service utilization and changes in rates of hospitalizations over time using restricted cubic spline regression. Secondary outcome measures included change in hospital costs for each hospitalization category over the study period.

RESULTS

Of 1,076,951 hospitalizations in young adults (73.7% female), 195,726 (18.2%) had a psychiatric disorder (either primary or comorbid). There were 129,676 hospitalizations (12.0%) with psychiatric disorders only, 36,287 (3.4%) with primary psychiatric and comorbid physical disorders, 29,763 (2.8%) with primary physical and comorbid psychiatric disorders, and 881,225 (81.8%) with physical disorders only. Rates of hospitalization for psychiatric disorders only increased 81% from 4.32 to 7.84/1,000 population, and those with physical health disorders with comorbid psychiatric disorders increased 172% from 0.47 to 1.28/1,000 population. Substance-related disorders were the most common comorbid psychiatric disorders among youth hospitalized for physical illness and increased 260% from 0.9 to 3.3/1,000 population.

DISCUSSION

Hospitalizations among young adults with primary and comorbid psychiatric disorders have increased significantly over the past 15 years. Health system resources should be adequately directed to meet the shifting and complex needs of hospitalized young adults.

Epidemiology and trends of alcohol use disorder and alcohol-associated liver disease

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Flow through the Emergency Department for Patients Presenting with Substance Use Disorder in Alberta, Canada

INTRODUCTION

Since 2016 the province of Alberta, Canada, has seen a significant increase in substance use disorder (SUD) presentations to the emergency department (ED) with a large surge during the COVID-19 pandemic. In this retrospective study we deconstruct the total length of stay (LOS) in the ED into stages for patients presenting with SUD and estimate the effects of covariates on the time to transition between stages.

METHODS

Using the Canadian Coding Standards for International Classification of Diseases, 10^th Modification, codes F10.0-F19.9 and T36.0-T50.9, we extracted data from the National Ambulatory Care Reporting System between April 1, 2019-March 31, 2020 on all ED presentations for SUD by Alberta residents. We used a multistate model to deconstruct the EDLOS into eight mutually exclusive states and determine which factors affected the time spent in each state.

RESULTS

We analyzed 66,880 presentations (37,530 patients). The mean age was 37.2 years, and 61% were male. The median total LOS in the ED was 6 hours 13 minutes. Patients presenting with methamphetamines (METH) intoxication and patients from low-income neighborhoods had significantly increased transition times between all states. Opposite this, opiate use was associated with faster transition times between almost all states. Metro EDs experienced slower transitions when attempting to discharge or admit patients when compared to urban or rural EDs. Emergency department crowding also had a dramatic effect on physician initial assessment times, while discharge and admission times in patients presenting with SUD were also significantly affected.

CONCLUSION

Patients with SUD experience a variety of delays during their ED stay. Those with METH intoxication and those from the lowest income neighborhoods were most likely to experience slower transitions from state to state in the ED and may benefit from a focused approach to improve ED flow.

Changes in health service use due to alcohol during the COVID-19 pandemic among individuals with and individuals without pre-existing alcohol-related medical diagnoses

OBJECTIVE

To compare changes in outpatient and acute care visits due to alcohol during the COVID-19 pandemic between individuals with and those without a history of alcohol-related health service use (AHSU).

METHODS

We conducted a cross-sectional analysis of health administrative data in Ontario, Canada. The Ontario population was stratified into those with and those without 1+ health service encounter(s) due to alcohol in the past 2 years. We compared age- and sex-standardized rates of alcohol-related outpatient visits, emergency department (ED) visits, and hospitalizations during the first 15 months of the pandemic (March 2020-May 2021) to those during the same 15-month period prior to the pandemic (March 2018-May 2019).

RESULTS

Of 13,450,750 eligible Ontarians on March 11, 2022, 129,434 (1.0%) had AHSU in the previous 2 years. Overall, rates of alcohol-related outpatient visits and hospitalizations increased, while rates of alcohol-related ED visits decreased during the pandemic. There was a similar relative increase in rates of alcohol-related outpatient visits and hospitalizations between those with and those without prior AHSU. However, the absolute increase in rates of alcohol-related outpatient visits and hospitalizations was higher among those with prior AHSU (outpatient rate difference (RD) per 10,000 population: 852.3, 95% confidence interval (CI): 792.7, 911.9; inpatient RD: 26.0, 95% CI: -2.3, 54.2) than among those without (outpatient RD: 6.5, 95% CI: 6.0, 6.9; inpatient RD: 0.4, 95% CI: 0.2, 0.7).

CONCLUSION

Rates of alcohol-related outpatient and inpatient care increased during the COVID-19 pandemic, and high rate of recurrent harm among individuals with pre-pandemic AHSU was an important contributor to this trend.

Understanding the association between neighbourhood socioeconomic status and grocery store alcohol sales following market liberalization in Ontario, Canada

OBJECTIVES

In 2015, Ontario partially deregulated alcohol sales by allowing grocery stores to sell alcohol. The purpose of this study was to evaluate (1) whether neighbourhood-level socioeconomic status (SES) impacted the likelihood that a grocery store began selling alcohol, and (2) whether increases in alcohol retail availability following deregulation differed between neighbourhoods based on SES.

METHODS

This was a repeated cross-sectional analysis of 1062 grocery stores in 17,096 neighbourhoods in urban Ontario. The association between neighbourhood-level SES and whether a grocery store began selling alcohol was modeled using mixed effect logistic regression. The annual change in drive-distance from a neighbourhood to the closest off-premise alcohol outlet between 2015 and 2020 was modeled using mixed effect linear regression. An interaction between time and SES was included to evaluate whether this change differed between neighbourhoods based on SES.

RESULTS

Grocery stores in neighbourhoods in the lowest SES quintile were 39% less likely to start selling alcohol than grocery stores in neighbourhoods in the highest SES quintile (odds ratio (OR): 0.61, 95% confidence interval (CI): 0.39-0.94). As grocery store sales expanded, the distance to the closest off-premise alcohol outlet decreased by 51.8 m annually (95% CI: 48.8-54.9, p < 0.01). A significant interaction between year and SES was observed whereby this trend was more pronounced in high- versus low-SES neighbourhoods.

CONCLUSION

The expansion of grocery store alcohol sales increased alcohol availability, but this increase was proportionately larger in high- versus low-SES neighbourhoods. This reduced historic disparities in alcohol availability between low- and high-SES neighbourhoods.

Trends in alcohol-attributable hospitalisations and emergency department visits by age, sex, drinking group and health condition in Ontario, Canada

INTRODUCTION

Alcohol-attributable harms are increasing in Canada. We described trends in alcohol-attributable hospitalisations and emergency department (ED) visits by age, sex, drinking group, attribution and health condition.

METHODS

Hospitalisation and ED visits for partially or wholly alcohol-attributable health conditions by age and sex were obtained from population-based health administrative data for individuals aged 15+ in Ontario, Canada. Population-level alcohol exposure was estimated using per capita alcohol sales and alcohol use data. We estimated the number and rate of alcohol-attributable hospitalisations (2008-2018) and ED visits (2008-2019) using the International Model of Alcohol Harms and Policies (InterMAHP).

RESULTS

Over the study period, the modelled rates of alcohol-attributable health-care encounters were higher in males, but increased faster in females. Specifically, rates of alcohol-attributable hospitalisations and ED visits increased by 300% (19-76 per 100,000) and 37% (774-1,064 per 100,000) in females, compared to 20% (322-386 per 100,000) and 2% (2563-2626 per 100,000) in males, respectively. Alcohol-attributable ED visit rates were highest among individuals aged 15-34, however, increased faster among individuals aged 65+ (females: 266%; males: 44%) than 15-34 years (females:+17%; males: -16%). High-volume drinkers had the highest rates of alcohol-attributable health-care encounters; yet, low-/medium-volume drinkers contributed substantial hospitalisations (11%) and ED visits (36%), with increasing rates of ED visits in females drinking low/medium volumes.

DISCUSSION AND CONCLUSIONS

Alcohol-attributable health-care encounters increased overall, and faster among females, adults aged 65+ and low-/medium-volume drinkers. Monitoring trends across subpopulations is imperative to inform equitable interventions to mitigate alcohol-attributable harms.

Risk factors associated with 1-week revisit among emergency department patients with alcohol withdrawal

BACKGROUND

Approximately one-quarter of emergency department (ED) visits for alcohol withdrawal result in unscheduled 1-week ED return visits, but it is unclear what patient and clinical factors may impact this outcome METHODS: From January 1, 2015, to December 31, 2018, at three urban EDs in Vancouver, Canada, we studied patients who were discharged with a primary or secondary diagnosis of alcohol withdrawal. We performed a structured chart review to ascertain patient characteristics, ED treatments, and the outcome of an ED return within 1 week of discharge. We used univariable and multivariable Bayesian binomial regression to identify characteristics associated with being in the upper quartile of 1-week ED revisits.

RESULTS

We collected 935 ED visits among 593 unique patients. Median age was 45 years (interquartile range 34 to 55 years) and 71% were male. The risk of a 1-week ED revisit was 15.0% (IQR 12.3; 19.5%). After adjustment, factors independently associated with a high risk for return included any prior ED visit within 30 days, no fixed address, initial blood alcohol level > 45 mmol/L, and initial Clinical Institute Withdrawal Assessment-alcohol revised score > 23. These factors explained 41% of the overall variance in revisits.

CONCLUSION

Among discharged ED patients with alcohol withdrawal, we describe high-risk patient characteristics associated with 1-week ED revisits, and these findings may assist clinicians to facilitate appropriate discharge planning with access to integrated follow-up support.

Clarifying rural-urban disparities in alcohol-related emergency department visits and hospitalizations in Ontario, Canada: A spatial analysis

PURPOSE

Rates of alcohol-related harm are higher in rural versus urban Canada. This study characterized the spatial distribution and regional determinants of alcohol-related emergency department (ED) visits and hospitalizations in Ontario to better understand this rural-urban disparity.

METHODS

This was a cross-sectional spatial analysis of rates of alcohol-related ED visits and hospitalizations by Ministry of Health subregion (n = 76) in Ontario, Canada between 2016 and 2019. Regional hot- and cold-spots of alcohol-related harm were identified using spatial autocorrelation methods. Rurality was measured as the population weighted geographic remoteness of a subregion. The associations between rurality and rates of alcohol-related ED visits and hospitalizations were evaluated using hierarchical Bayesian spatial regression models.

FINDINGS

Rates of alcohol-related ED visits and hospitalizations varied substantially between subregions, with high rates clustering in Northern Ontario. Overall, increasing rurality was associated with higher subregion-level rates of alcohol-related ED visits (males adjusted relative rate [aRR]: 1.67, 95% credible interval [CI]: 1.49-1.87; females aRR: 1.78, 95% CI: 1.60-1.98) and hospitalizations (males aRR: 1.34, 95% CI: 1.24-1.45; females aRR: 1.59, 95% CI: 1.45-1.74). However, after the province was separated into Northern and Southern strata, this association only held in Northern subregions. In contrast, increasing rurality was associated with lower rates of alcohol-related ED visits in Southern subregions (males aRR: 0.87, 95% CI: 0.79-0.96; females aRR: 0.88, 95% CI: 0.81-0.97).

CONCLUSIONS

There are regional differences in the association between rurality and alcohol-related health service use. This regional variation should be considered when developing health policies to minimize geographic disparities in alcohol-related harm.

Rural-urban disparities in post-discharge outcomes following alcohol-related hospitalizations in Ontario, Canada: A retrospective cohort study

BACKGROUND

Limited access to mental health and addiction (MHA) services in rural areas may increase the risk of recurrent alcohol-related harm among rural, relative to urban, residents. This study evaluated (1) rural-urban differences in clinical trajectories following alcohol-related hospitalizations and (2) whether limited access to MHA services mediates an increased risk of adverse post-discharge outcomes in rural areas.

METHODS

This was a population-based retrospective cohort study of individuals in Ontario, Canada, who experienced an alcohol-related hospitalization between 2016 and 2018. The primary exposure was rurality. The outcomes of interest were outpatient MHA care, alcohol-related emergency department visits, alcohol-related hospitalizations, and all-cause mortality within one-year of discharge from the index alcohol-related hospitalization. Data were collected using provincial health administrative databases. The associations between rurality and the time to each outcome were assessed using multivariable time-to-event regression. Mediation analyses were conducted using a counterfactual approach.

RESULTS

46,657 individuals were included. 11.5% of the cohort died within one year of discharge from the index alcohol-related hospitalization. Relative to urban residents, rural residents were less likely to receive MHA outpatient care (adjusted hazard ratio (aHR): 0.80, 95% confidence interval (CI): 0.75-0.86) and more likely to die (aHR: 1.19, 95% CI: 1.06-1.34) in the year following discharge. The lower likelihood of post-discharge MHA-related care among rural residents mediated 31% (95% CI: 13-46%) of the increased risk of mortality.

CONCLUSIONS

A lack of follow-up MHA care mediates an increased risk of short-term mortality following alcohol-related hospitalizations in rural, relative to urban, communities.

Why Are Some Male Alcohol Misuse Disorder Patients High Utilisers of Emergency Health Services? An Asian Qualitative Study

BACKGROUND

Certain alcohol misuse patients heavily utilise the Emergency Department (ED) and Emergency Medical Services (EMS) and may present with intoxication or long-term sequelae of alcohol misuse. Our study explored reasons for repeated ED/EMS utilisation and sought to understand perpetuating and protective factors for drinking.

METHODS

Face-to-face semi-structured qualitative interviews were conducted. Participants were recruited from an ED in Singapore. Interviews were audio-recorded, transcribed verbatim and underwent manual thematic analysis. Emergent themes were independently reviewed for agreement. Data from medical records, interview transcripts, and field notes were triangulated for analysis.

RESULTS

All participants were male (n = 20) with an average age of 55.6 years (SD = 8.86). Most were unemployed (75%), did not have tertiary education (75%), were divorced (55%), and had pre-existing psychiatric conditions (60%) and chronic cardiovascular conditions (75%). Reasons for utilisation included a perceived need due to symptoms, although sometimes it was bystanders who called the ambulance. ED/EMS was preferred due to the perceived higher quality and speed of care. Persistent drinking was attributed to social and environmental factors, and as a coping mechanism for stressors. Rehabilitation programs and meaningful activities reduced drinking tendencies.

CONCLUSION

ED/EMS provide sought-after services for alcohol misuse patients, resulting in high utilisation. Social and medical intervention could improve drinking behaviours and decrease overall ED/EMS utilisation.

Socioeconomic and Geographic Disparities in Emergency Department Visits due to Alcohol in Ontario: A Retrospective Population-level Study from 2003 to 2017

OBJECTIVE

While the overall health system burden of alcohol is large and increasing in Canada, little is known about how this burden differs by sociodemographic factors. The objectives of this study were to assess sociodemographic patterns and temporal trends in emergency department (ED) visits due to alcohol to identify emerging and at-risk subgroups.

METHODS

We conducted a retrospective population-level cohort study of all individuals aged 10 to 105 living in Ontario, Canada. We identified ED visits due to alcohol between 2003 and 2017 using defined International Classification of Diseases, 10th edition, codes from a pre-existing indicator. We calculated annual age- and sex-standardized, and age- and sex-specific rates of ED visits and compared overall patterns and changes over time between urban and rural settings and income quintiles.

RESULTS

There were 829,662 ED visits due to alcohol over 15 years. Rates of ED visits due to alcohol were greater for individual living in the lowest- compared to the highest-income quintile neighbourhoods, and disparities (rate ratio lowest to highest quintile) increased with age from 1.22 (95% CI, 1.19 to 1.25) in 15- to 18-year-olds to 4.17 (95% CI, 4.07 to 4.28) in 55- to 59-year-olds. Rates of ED visits due to alcohol were significantly greater in rural settings (56.0 per 10,000 individuals, 95% CI, 55.7 to 56.4) compared to urban settings (44.8 per 10,000 individuals, 95% CI, 44.7 to 44.9), particularly for young adults. Increases in rates of visits between 2003 and 2017 were greater in rural versus urban settings (82 vs. 68% increase in age- and sex-standardized rates) and varied across sociodemographic subgroups with the largest annual increases in rates of visits in young (15 to 29) low-income women (6.9%, 95%CI, 6.7 to 7.3) and the smallest increase in older (45 to 59) high-income men (2.7, 95%CI, 2.4 to 3.0).

CONCLUSION

Alcohol harms display unique patterns with the highest burden in rural and lower-income populations. Rural-urban and income-based disparities differ by age and sex and have increased over time, which offers an imperative and opportunity for further interventions by clinicians and policy makers.

Nationwide Alcohol-related visits In Singapore's Emergency departments (NAISE): A retrospective population-level study from 2007 to 2016

INTRODUCTION

Excessive alcohol consumption is associated with increased morbidity and mortality, and its societal impact is substantial. The Nationwide Alcohol-related visits In Singapore Emergency departments study aims to characterise trends in ED visits involving acute and chronic alcohol consumption between 2007 and 2016.

METHODS

Data from the Singapore Ministry of Health, comprising all ED visits in Singapore from 2007 to 2016, were used. The data were aggregated by year and analysed for changes in prevalence and rates of ED visits for acute and chronic alcohol consumption, broken down by age, gender and ethnicity.

RESULTS

Over the study period, the number of ED visits involving alcohol consumption increased 98.3%, from 2236 in 2007 to 4433 in 2016. During the same period, the rate per 100 000 population increased 62.4% from 48.7 to 79.1, and total ED-related costs rose by 140%, from 528 680 to 1 269 638 SGD. The increase in alcohol-related visits rates and costs was higher than non-alcohol-related visits rates and costs, which increased by 12.1% and 115% respectively. While trends in acute and chronic alcohol-related ED visits stayed stable amongst women, they rose substantially in men. Older men aged 50-69 show the highest rates and rate of increase for both acute and chronic alcohol-related ED visits.

DISCUSSION AND CONCLUSIONS

Alcohol-related visits contributed disproportionately to the increasing number of ED visits in Singapore between 2007 and 2016. Older men form the demographic with the highest rates and increase in rates of alcohol-related ED visits and form a potential group for targeted intervention.

Assessment of Age and Sex Differences in Risk of 1-Year Mortality After Emergency Department Visits Caused by Alcohol Use

This cross-sectional study assesses age and sex differences in risk of 1-year mortality in patients with emergency department visits due to alcohol compared with the general population in Ontario, Canada.

Measuring Substance-Related Disorders Using Canadian Administrative Health Databanks: Interprovincial Comparisons of Recorded Diagnostic Rates, Incidence Proportions and Mortality Rate Ratios

CONTEXT

Assessing temporal changes in the recorded diagnostic rates, incidence proportions, and health outcomes of substance-related disorders (SRD) can inform public health policymakers in reducing harms associated with alcohol and other drugs.

OBJECTIVE

To report the annual and cumulative recorded diagnostic rates and incidence proportions of SRD, as well as mortality rate ratios (MRRs) by cause of death among this group in Canada, according to their province of residence.

METHODS

Analyses were performed on linked administrative health databases (AHD; physician claims, hospitalizations, and vital statistics) in five Canadian provinces (Alberta, Manitoba, Ontario, Québec, and Nova Scotia). Canadians 12 years and older and registered for their provincial healthcare coverage were included. The International Classification of Diseases (ICD-9 or ICD-10 codes) was used for case identification of SRD from April 2001 to March 2018.

RESULTS

During the study period, the annual recorded SRD diagnostic rates increased in Alberta (2001-2002: 8.0‰; 2017-2018: 12.8‰), Ontario (2001-2002: 11.5‰; 2017-2018: 14.4‰), and Nova Scotia (2001-2002: 6.4‰; 2017-2018: 12.7‰), but remained stable in Manitoba (2001-2002: 5.5‰; 2017-2018: 5.4‰) and Québec (2001-2002 and 2017-2018: 7.5‰). Cumulative recorded SRD diagnostic rates increased steadily for all provinces. Recorded incidence proportions increased significantly in Alberta (2001-2002: 4.5‰; 2017-2018: 5.0‰) and Nova Scotia (2001-2002: 3.3‰; 2017-2018: 3.8‰), but significantly decreased in Ontario (2001-2002: 6.2‰; 2017-2018: 4.7‰), Québec (2001-2002: 4.1‰; 2017-2018: 3.2‰) and Manitoba (2001-2002: 2.7‰; 2017-2018: 2.0‰). For almost all causes of death, a higher MRR was found among individuals with recorded SRD than in the general population. The causes of death in 2015-2016 with the highest MRR for SRD individuals were SRD, suicide, and non-suicide trauma in Alberta, Ontario, Manitoba, and Québec.

DISCUSSION

Linked AHD covering almost the entire population can be useful to monitor the medical service trends of SRD and, therefore, guide health services planning in Canadian provinces.

NAFLD and Alcohol-Associated Liver Disease Will Be Responsible for Almost All New Diagnoses of Cirrhosis in Canada by 2040

BACKGROUND AND AIMS

Mortality secondary to cirrhosis in North America is increasing. We describe the incidence of cirrhosis stratified by birth cohort and cirrhosis etiology and project disease burden to 2040.

APPROACH AND RESULTS

This is a retrospective cohort study in Ontario, Canada, using population-based administrative health care data. Individuals with incident cirrhosis (2000-2017) were identified, and etiology was defined as HCV, HBV, NAFLD, alcohol-associated liver disease (ALD), or autoimmune liver disease/other using validated case definitions. Annual age/sex-adjusted cirrhosis incidence rate per 100,000 person-years was calculated with incidence projection to 2040 using age-period-cohort modeling along with average annual percent change (AAPC) in cirrhosis incidence stratified by birth cohort and etiology. In total, 159,549 incident cases of cirrhosis were identified. Incidence increased by 26% with an AAPC of 2%/year (95% CI, 1.6-2.4; P < 0.001). The largest increases were for HCV (AAPC, 4.1%/year; 95% CI, 2.6-5.7; P < 0.001) and NAFLD (AAPC, 3.3%/year; 95% CI, 2.6-4.1%; P < 0.001). ALD and HCV cirrhosis in those born >1980 increased by 11.6%/year (95% CI, 9.3-13.9; P < 0.001) and 9.5%/year (95% CI, 6.2-13.0; P < 0.001), respectively. However, by 2040, cirrhosis incidence is projected to continue to increase, driven mostly by NAFLD, especially in postmenopausal women, and ALD in individuals born >1980.

CONCLUSIONS

Cirrhosis incidence will continue to increase over the next two decades secondary to NAFLD with a worrisome rapid rise in ALD cirrhosis among young adults. Public education, policy, and intervention targeting NAFLD risk factors and alcohol use in young adults are urgently needed.

Changes in the dollar value of per capita alcohol, essential, and non-essential retail sales in Canada during COVID-19

Background

Multiple survey reports suggest that alcohol use has increased in Canada during the COVID-19 pandemic. However, less is known about how per capita alcohol sales, which predict population-level alcohol use, have changed and whether changes in alcohol sales differ from changes in sales of other products due to pandemic factors.

Methods

We obtained monthly retail sales data by industry from Statistics Canada, for the six largest provinces in Canada (containing 93% of the national population), between January 2010 and November 2020, representing time before and 9 months after the start of the pandemic in Canada. We used an interrupted time series analysis to estimate pandemic impacts on the dollar value of monthly per capita (per individuals 15+ years) alcohol, essential and non-essential retail sales. We adjusted our analyses for pre-pandemic sales trends, inflation, seasonality and changing population demographics over time.

Results

During the first 9 months of the pandemic, the values of per capita alcohol, essential and non-essential sales were, respectively, 13.2% higher, 3.6% higher and 13.1% lower than the average values during the same period in the prior 3 years. Interrupted time series models showed significant level change for the value of monthly per capita alcohol sales (+$4.86, 95% CIs: 2.88, 6.83), essential sales (−$59.80, 95% CIs: − 78.47, − 41.03) and non-essential sales (−$308.70, 95% CIs: − $326.60, − 290.79) during the pandemic. Alcohol sales were consistently elevated during the pandemic, and the pre- and post-pandemic slopes were comparable. In contrast, essential and non-essential retail sales declined in the early months of the pandemic before returning to regular spending levels.

Conclusion

During the first 9 months of the pandemic, per capita alcohol sales were moderately elevated in Canada. In contrast, non-essential sales were lower than prior years, driven by large decreases during the initial months of the pandemic. These findings suggest that the pandemic was associated with increased population-level alcohol consumption, which may lead to increased alcohol-related harms. Ongoing research is needed to examine how factors, including pandemic-related stressors and specific alcohol sales-related policies, may have influenced changes in alcohol use and harms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12226-1.

Applying a gendered lens to understanding self-reported changes in alcohol and cannabis consumption during the second wave of the COVID-19 pandemic in Canada, September to December 2020

INTRODUCTION

Increased alcohol and cannabis consumption and related harms have been reported since the beginning of the COVID-19 pandemic. Existing evidence shows that substance use and related harms differ by gender. Yet, no Canadian study has applied a gendered lens to alcohol and cannabis consumption use during this time. Our objectives were to (1) provide gender-specific prevalence estimates of self-reported increased alcohol and cannabis use; and (2) examine gender-specific associations between sociodemographic and mental health variables and alcohol and cannabis use.

METHODS

Using data from the Survey on COVID-19 and Mental Health, we calculated nationally representative, gender-specific prevalence estimates and disaggregated them by sociodemographic and mental health variables. Four logistic regression models were used to assess the likelihood of self-reported increased alcohol and cannabis use.

RESULTS

The prevalence of self-reported increase in alcohol use (16.2% women; 15.2% men) and cannabis use (4.9% women; 5.8% men) did not differ by gender. For both genders, income, racialized group membership, working in the past week, being a parent/legal guardian of a child aged under 18 and screening positive for depression and anxiety were associated with increased alcohol use. Men and women who were between the ages of 18 to 44, screened positive for depression, or both, were more likely to report increased cannabis use. For women, education was significantly associated with increased alcohol use. For men, being a parent/legal guardian was significantly associated with lower odds of increased cannabis use.

CONCLUSION

Sociodemographic factors, as well as depression and anxiety, were similarly associated with increased alcohol and cannabis use for both men and women in the second wave of the pandemic.

Prevention of alcohol withdrawal seizure recurrence and treatment of other alcohol withdrawal symptoms in the emergency department: a rapid review

Background

Patients who experience harms from alcohol and other substance use often seek care in the emergency department (ED). ED visits related to alcohol withdrawal have increased across the world during the COVID-19 pandemic. ED clinicians are responsible for risk-stratifying patients under time and resource constraints and must reliably identify those who are safe for outpatient management versus those who require more intensive levels of care. Published guidelines for alcohol withdrawal are largely limited to the primary care and outpatient settings, and do not provide specific guidance for ED use. The purpose of this review was to synthesize published evidence on the treatment of alcohol withdrawal syndrome in the ED.

Methods

We conducted a rapid review by searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (1980 to 2020). We searched for grey literature on Google and hand-searched the conference abstracts of relevant addiction medicine and emergency medicine professional associations (2015 to 2020). We included interventional and observational studies that reported outcomes of clinical interventions aimed at treating alcohol withdrawal syndrome in adults in the ED.

Results

We identified 13 studies that met inclusion criteria for our review (7 randomized controlled trials and 6 observational studies). Most studies were at high/serious risk of bias. We divided studies based on intervention and summarized evidence narratively. Benzodiazepines decrease alcohol withdrawal seizure recurrence and treat other alcohol withdrawal symptoms, but no clear evidence supports the use of one benzodiazepine over another. It is unclear if symptom-triggered benzodiazepine protocols are effective for use in the ED. More evidence is needed to determine if phenobarbital, with or without benzodiazepines, can be used safely and effectively to treat alcohol withdrawal in the ED. Phenytoin does not have evidence of effectiveness at preventing withdrawal seizures in the ED.

Conclusions

Few studies have evaluated the safety and efficacy of pharmacotherapies for alcohol withdrawal specifically in the ED setting. Benzodiazepines are the most evidence-based treatment for alcohol withdrawal in the ED. Pharmacotherapies that have demonstrated benefit for treatment of alcohol withdrawal in other inpatient and outpatient settings should be evaluated in the ED setting before routine use.

Aspiration risk in relation to Glasgow Coma Scale score and clinical parameters in patients with severe acute alcohol intoxication: a single-centre, retrospective study

OBJECTIVES

In alcohol intoxicated patients, the decision for or against airway protection can be challenging and is often based on the Glasgow Coma Scale (GCS). Primary aim of this study was to analyse the aspiration risk in relation to the GCS score and clinical parameters in patients with severe acute alcohol monointoxication. Secondary aim was the association between the blood alcohol level and the GCS score.

SETTING

Single-centre, retrospective study of alcoholised patients admitted to a German intensive care unit between 2006 and 2020.

PARTICIPANTS

A total of n=411 admissions were eligible for our analysis.

CLINICAL MEASURES AND ANALYSIS

The following data were extracted: age, gender, admission time, blood alcohol level, blood glucose level, initial GCS score, GCS score at admission, vital signs, clinical signs of aspiration and airway management measures. The empirical distribution of continuous and categorical data was calculated. Binary multivariable logistic regression analysis was used to identify possible risk factors for aspiration.

RESULTS

The mean age was 35 years. 72% (n=294) of the admissions were male. The blood alcohol level (mean 2.7 g/L±1.0, maximum 5.9 g/L) did not correlate with the GCS score but with the age of the patient. In univariate analysis, the aspiration risk correlated with blood alcohol level, age, GCS score, oxygen saturation, respiratory rate and blood glucose level and was significantly higher in male patients, on vomiting, and in patients requiring airway measures. Aspiration rate was 45% (n=10) in patients without vs 6% (n=3) in patients with preserved protective reflexes (p=0.0001). In the multivariate analysis, only age and GCS score were significantly associated with the risk of aspiration.

CONCLUSION

Although in this single-centre, retrospective study the aspiration rate in severe acute alcohol monointoxicated patients correlates with GCS and protective reflexes, the decision for endotracheal intubation might rather be based on the presence of different risk factors for aspiration.

Use of pharmacotherapy for alcohol use disorder in Manitoba, Canada: A whole-population cohort study

OBJECTIVE

Update the evidence on use of pharmacotherapy for alcohol use disorder in a Canadian population.

METHODS

Using whole-population administrative data from Manitoba, Canada, we identified all residents age 12+ who were first diagnosed with alcohol use disorder between April 1, 1996 and March 31, 2015, and compared characteristics of those who filled a prescription for naltrexone, acamprosate or disulfiram at least once during that period to those who did not fill a prescription for an alcohol use disorder medication.

RESULTS

Only 1.3% of individuals with alcohol use disorder received pharmacotherapy (62.3% of prescriptions were for naltrexone, 39.4% for acamprosate, 7.5% for disulfiram). Most prescriptions came from family physicians in urban alcohol use disorder (53.6%) and psychiatrists (22.3%). Individuals were more likely to fill a prescription for alcohol use disorder medication if they lived in an urban vs rural environment (OR 2.25; 95% CI 1.83-2.77) or had a mood/anxiety disorder diagnosis vs no diagnosis (OR 2.40, 95% CI 1.98-2.90) in the five years before being diagnosed with alcohol use disorder.

CONCLUSION

Despite established evidence for the effectiveness of pharmacotherapy for alcohol use disorder, these medications continue to be profoundly underutilized in Canada.

Socio-demographic factors related to binge drinking in Ontario

BACKGROUND

Alcohol consumption has been linked to harmful health short and long-term outcomes. An analysis of socio-demographic factors related to binge drinking may help to identify groups at risk and provide primary health care providers an opportunity to assist members of those groups. In this study, we examined socio-demographic factors associated with binge drinking in Ontario, Canada.

METHODS

This analysis used data from a cross-sectional survey of Ontario adults (ages 19 and older) for the 2015-2017 period. Bivariate and multivariate adjusted analyses examined the association between binge drinking and socio-demographic factors. These analyses were also stratified by sex.

RESULTS

Increased alcohol binge drinking was associated with several socio-demographic factors including younger age groups, lower educational attainment, lower household income quintile, having immigrated to Canada within past 10 years, being male, reporting poorer mental health, being single, living in rural areas, and being unemployed. No differences were noted by households with or without children or by sexual orientation. Many of the factors associated with binge drinking remained significant when stratified by sex.

DISCUSSION

These findings suggest that several socio-demographic factors are associated with binge drinking. These can be helpful indicators for decision makers responsible for programs and policies aimed at reducing alcohol binge drinking, and for primary care providers, who in a brief intervention can screen for binge drinking and support those individuals by connecting them with local resources to reduce their harmful alcohol consumption habits.

Sociodemographic changes in emergency department visits due to alcohol during COVID-19

INTRODUCTION

Little detailed sociodemographic information is available about how alcohol use and associated health care visits have changed during COVID-19. Therefore, we assessed how rates of emergency department (ED) visits due to alcohol have changed during COVID-19 by age and sex and for individuals living in urban and rural settings and low and high-income neighborhoods.

METHODS

Our cohort included 13,660,516 unique Ontario residents between the ages of 10-105. We compared rates and characteristics of ED visits due to alcohol, identified using ICD-10 codes, from March 11-August 31 2020 to the same period in the prior 3 years. We used negative binomial regressions to examine to examine changes is visits during COVID-19 after accounting for temporal and seasonal trends.

RESULTS

During COVID-19, the average monthly rate of ED visits due to alcohol decreased by 17.2 % (95 % CI -22.7, -11.3) from 50.5-40.9 visits per 100,000 individuals. In contrast, the proportion of all-cause ED visits due to alcohol increased by 11.4 % (95 % CI 7.7, 15.3) from 15.0 visits to 16.3 visits per 1000 all cause ED visits. Changes in ED visits due to alcohol were similar for men in women. Decreases in visits were larger for younger adults compared to older adults and pre-COVID-19 disparities in rates of ED visits due to alcohol between urban and rural settings and low and high-income neighborhoods widened. ED visits related to harms from acute intoxication showed the largest declines during COVID-19, particularly in younger adults and urban and high-income neighborhoods.

CONCLUSION

ED visits due to alcohol decreased during the first six months of COVID-19, but to a lesser extent than decreases in all-cause ED visits. Our data suggest a widening of geographic and income-based disparities in alcohol harms in Ontario during COVID-19 which may require immediate and long-term interventions to mitigate.

Changes in Rates of Hospitalizations due to Cannabis Harms in Ontario, Canada Before the Legalization of Nonmedical Cannabis: Retrospective Population-level Study Between 2003 and 2017

OBJECTIVES

To assess the burden of hospitalizations due to cannabis harms in Ontario, Canada before Canada's legalization of nonmedical cannabis.

METHODS

We conducted a retrospective population-level study that included all individuals living in Ontario between 2003 and 2017. We described patterns of hospitalizations due to cannabis harms in men and women by demographics, socioeconomic factors, and mental health comorbidities. We calculated annual crude rates of hospitalizations due to cannabis harms and assessed time trends using Poisson regression models.

RESULTS

There were 39,092 hospitalizations due to cannabis harms among 32,811 unique individuals. Annual hospitalizations due to a cannabis harm increased by 280% between 2003 and 2017 (1712 vs 4730), with increases noted for all age groups and sexes. Rates of hospitalizations due to cannabis harms were greater in young adults, low-income individuals, and those with mental health comorbidities. Overall, the rate of hospitalizations due to cannabis harms increased on average by 7.8% per year (95% CI 7.5-8.0). Women aged 15 to 24 experienced the largest average annual increase (12.2% per year, 95% CI 11.5 to 12.8).

CONCLUSIONS

There are distinct patterns of hospitalizations due to cannabis harms in different priority populations. Young women aged 15 to 24 are a key demographic that is disproportionately burdened with a rapid increase in hospitalizations due to cannabis harms. Jurisdictions considering new approaches to cannabis control policy and addiction services should consider the rising burden of harms faced by youth and young adults when planning interventions.

Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy

OBJECTIVE

To establish national standards of care for screening and counselling pregnant women and women of child-bearing age about alcohol consumption and possible alcohol use disorder based on current best evidence.

INTENDED USERS

Health care providers who care for pregnant women and women of child-bearing age.

TARGET POPULATION

Pregnant women and women of child-bearing age and their families.

EVIDENCE

Medline, EMBASE, and CENTRAL databases were searched for "alcohol use and pregnancy." The results were filtered for a publication date between 2010 and September 2018. The search terms were developed using Medical Subject Headings terms and keywords, including pre-pregnancy, pregnant, breastfeeding, lactation, female, women, preconception care, prenatal care, fetal alcohol spectrum disorder, prenatal alcohol exposure, drinking behavior, alcohol abstinence, alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol consumption, alcohol abuse, benzodiazepines, disulfiram, naltrexane, acamprosate, ondansetron, topiramate, cyanamide, calcium carbimide, alcohol deterrents, disease management, detoxification, Alcoholics Anonymous, alcohol counselling, harm reduction, pre-pregnancy care, prenatal care, incidence, prevalence, epidemiological monitoring, and brief intervention. Evidence was included from clinical trials, observational studies, reviews, systematic reviews and meta-analyses, guidelines, and conference consensus.

VALIDATION METHODS

The content and recommendations in this guideline were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework.

BENEFITS, HARMS, COSTS

Implementation of the recommendations in these guidelines using validated screening tools and brief intervention approaches may increase obstetrical care provider recognition of alcohol consumption and problematic alcohol use among women of child-bearing age and those who are pregnant. It is anticipated that health care providers will become confident and competent in managing and supporting these women so they can achieve optimal health and pregnancy outcomes.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Benefits of Digital Health Resources for Substance Use Concerns in Women: Scoping Review

BACKGROUND

Digital health resources are being increasingly used to support women with substance use concerns. Although empirical research has demonstrated that these resources have promise, the available evidence for their benefit in women requires further investigation. Evidence supports the capacity of interventions that are sex-, gender-, and trauma-informed to improve treatment access and outcomes and to reduce health system challenges and disparities. Indeed, both sex- and gender-specific approaches are critical to improve health and gender equity. Violence and trauma are frequent among those with substance use concerns, but they disproportionately affect those who identify as female or women, further underscoring the need for trauma-informed care as well.

OBJECTIVE

The objective of this investigation was to evaluate the evidence supporting the efficacy or effectiveness of online or mobile interventions for risky or harmful substance use in adults who identify as female or women, or who report a history of trauma.

METHODS

This scoping review is based on an academic search in MEDLINE, APA PsycINFO, Embase, Cochrane Central, and CINAHL, as well as a grey literature search in US and Canadian government and funding agency websites. Of the 7807 records identified, 465 remained following title and abstract screening. Of these, 159 met all eligibility criteria and were reviewed and synthesized.

RESULTS

The 159 records reflected 141 distinct studies and 125 distinct interventions. Investigations and the interventions evaluated predominantly focused on alcohol use or general substance use. Evaluated digital health resources included multisession and brief-session interventions, with a wide range of therapeutic elements. Multisession online and mobile interventions exhibited beneficial effects in 86.1% (105/122) of studies. Single-session interventions similarly demonstrated beneficial effects in 64.2% (43/67) of study conditions. Most investigations did not assess gender identity or conduct sex- or gender-based analyses. Only 13 investigations that included trauma were identified.

CONCLUSIONS

Despite the overall promise of digital health interventions for substance use concerns, direct or quantitative evidence on the efficacy or effectiveness of interventions in females or women specifically is weak.

Epigenetic Impacts of Early Life Stress in Fetal Alcohol Spectrum Disorders Shape the Neurodevelopmental Continuum

Neurodevelopment in humans is a long, elaborate, and highly coordinated process involving three trimesters of prenatal development followed by decades of postnatal development and maturation. Throughout this period, the brain is highly sensitive and responsive to the external environment, which may provide a range of inputs leading to positive or negative outcomes. Fetal alcohol spectrum disorders (FASD) result from prenatal alcohol exposure (PAE). Although the molecular mechanisms of FASD are not fully characterized, they involve alterations to the regulation of gene expression via epigenetic marks. As in the prenatal stages, the postnatal period of neurodevelopment is also sensitive to environmental inputs. Often this sensitivity is reflected in children facing adverse conditions, such as maternal separation. This exposure to early life stress (ELS) is implicated in the manifestation of various behavioral abnormalities. Most FASD research has focused exclusively on the effect of prenatal ethanol exposure in isolation. Here, we review the research into the effect of prenatal ethanol exposure and ELS, with a focus on the continuum of epigenomic and transcriptomic alterations. Interestingly, a select few experiments have assessed the cumulative effect of prenatal alcohol and postnatal maternal separation stress. Regulatory regions of different sets of genes are affected by both treatments independently, and a unique set of genes are affected by the combination of treatments. Notably, epigenetic and gene expression changes converge at the clustered protocadherin locus and oxidative stress pathway. Functional studies using epigenetic editing may elucidate individual contributions of regulatory regions for hub genes and further profiling efforts may lead to the development of non-invasive methods to identify children at risk. Taken together, the results favor the potential to improve neurodevelopmental outcomes by epigenetic management of children born with FASD using favorable postnatal conditions with or without therapeutic interventions.

Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study

BACKGROUND

Little is known about the risk of death among people who visit emergency departments frequently for alcohol-related reasons, including whether mortality risk increases with increasing frequency of visits. Our primary objective was to describe the sociodemographic and clinical characteristics of this high-risk population and examine their 1-year overall mortality, premature mortality and cause of death as a function of emergency department visit frequency in Ontario, Canada.

METHODS

We conducted a population-based retrospective cohort study using linked health administrative data (Jan. 1, 2010, to Dec. 31, 2016) in Ontario for people aged 16-105 years who made at least 2 emergency department visits for mental or behavioural disorders due to alcohol within 1 year. We subdivided the cohort based on visit frequency (2, 3 or 4, or ≥ 5). The primary outcome was 1-year mortality, adjusted for age, sex, income, rural residence and presence of comorbidities. We examined premature mortality using years of potential life lost (YPLL).

RESULTS

Of the 25 813 people included in the cohort, 17 020 (65.9%) had 2 emergency department visits within 1 year, 5704 (22.1%) had 3 or 4 visits, and 3089 (12.0%) had 5 or more visits. Males, people aged 45-64 years, and those living in urban centres and lower-income neighbourhoods were more likely to have 3 or 4 visits, or 5 or more visits. The all-cause 1-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common. The adjusted mortality rate was 38% higher for patients with 5 or more visits than for those with 2 visits (adjusted hazard ratio 1.38, 95% confidence interval 1.19-1.59). Among 25 298 people aged 16-74 years, this represented 30 607 YPLL.

INTERPRETATION

We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.

Who is asked about alcohol consumption? A retrospective cohort study using a national repository of Electronic Medical Records

Documentation of alcohol use in electronic medical record (EMR) informs interventions to reduce alcohol-related morbidity and mortality. This retrospective cohort study explored EMR data from 960 primary care providers participating in the Canadian Primary Care Sentinel Surveillance Network to describe documentation of alcohol use (e.g. none, current or past use) in the EMR. Included providers represented 700,620 adult patients from across Canada with an encounter between 2015 and 2018. Bivariate comparisons characterized the patients with, and without, documentation of alcohol use. Multivariate generalized estimating equation models with logit function assessed patient and provider characteristics associated with (1) documentation of alcohol and (2) patients with heightened risk for alcohol-related problems. Forty percent of patients had alcohol use documentation in the EMR. Light alcohol consumption was recorded for 43.6% of these patients. Male patients (OR1.09, CI 1.07-1.12), who were older (OR1.26, CI 1.23-1.30), had more frequent visits to their provider (OR1.11, CI 1.09-1.13) and had hypertension (OR1.07, CI 1.06-1.09) or depression (OR1.07, CI 1.09-1.14) had higher odds of alcohol documentation. There were 4.7% of patients with a record indicating heightened risk for alcohol-related problems. Male patients (OR3.27 CI 3.14-3.4), patients with depression (OR2.01 CI1.93-2.1) and rural residency (OR1.35 CI1.29-1.42) was associated with risk for alcohol-related problems. Heavy alcohol consumption is associated with an increased risk of negative health outcomes, particularly for patients with certain chronic conditions. However, these patients do not have alcohol use consistently documented in the EMR. Strategies should be designed and implemented to support more consistent alcohol-screening among high-risk patients.

Secular trends in adolescents' diagnosed health status and healthcare consultation: examinations of Canadian national surveys from 2007 to 2016

OBJECTIVES

The objective of this study was to investigate secular trends in adolescent health status and healthcare consultations.

STUDY DESIGN

The design of this study is cross-sectional comparisons of population survey outcomes.

METHODS

Canadian national population data from 2007 to 2016 (T1 N = 14,223; T2 N = 14,247; T3 N = 13,532; T4 N = 13,184; T5 N = 11,122; Total N = 66,308) were examined to find trends in health diagnosis (chronic illnesses and mental disorders) and healthcare consultation (general health practitioners and mental health professionals). Controlling demographics, Multivariate analysis of covariances (MANCOVAs) and correlations were carried out to compare differences by age group (A1: 12-14 years N = 25,180; A2: 15-17 years N = 25,825; A3: 18-19 years N = 15,303) and gender (girls N = 32,388; boys N = 33,920) across survey years.

RESULTS

Steady increases were found in diagnosed mental disorders and consultations with a mental health professional (MP) for girls, while chronic illnesses remained stable and general practitioner consultations declined for all adolescents over these years. Gender disparity in MP consultations grew with age, much more in recent years, whereas chronic illness diagnoses curved down for all in midadolescence. More integrated relations between health status and healthcare utilization were noted in T5 than in T1.

CONCLUSIONS

Differential secular trends were shown for adolescent physical versus mental health statuses and relevant healthcare consultations. Although girls' and older adolescents' mental health declined over the years, a positive direction was also found for improved awareness of mental health.

Health service use among Manitobans with alcohol use disorder: a population-based matched cohort study

BACKGROUND

Alcohol is the drug most commonly used by Canadians, with multiple impacts on health and health service use. We examined patterns of short- and long-term health service use among people with a diagnosis of alcohol use disorder.

METHODS

In this retrospective matched cohort study, we used population-based administrative data from the province of Manitoba, Canada, to identify individuals aged 12 years or older with a first indication of alcohol use disorder (index date) in the period 1990 to 2015. We matched cases (those with diagnosis of alcohol use disorder) to controls (those without this diagnosis), at a 1:5 ratio, on the basis of age, sex, geographic region and income quintile at the index date. The outcome measures were inpatient hospital admission, outpatient physician visits, emergency department visits and use of prescription medications. We modelled crude rates using generalized estimating equations with either a negative binomial or a Poisson distribution RESULTS: We identified 53 410 people with alcohol use disorder and 264 857 matched controls. All outcomes occurred at a higher rate among people with the disorder than among controls. For example, during the year of diagnosis, the rate ratio for hospital admission was 4.0 (95% confidence interval [CI] 3.9-4.2) for women and 4.5 (95% CI 4.4-4.7) for men. All rates of health service use peaked close to the index date, but remained significantly higher among people with alcohol use disorder than among controls for 20 years. Among people with alcohol use disorder, the most commonly filled prescriptions were for psycholeptics, whereas among controls, the most commonly filled prescriptions were for sex hormones (women) and antihypertensives (men).

INTERPRETATION

Compared with controls, people with alcohol use disorder used significantly more health services from the time of diagnosis and over the next 20 years. This finding highlights the need for better detection and early intervention to reduce the need for acute and emergency care, as well as the need for improved management of alcohol use disorder over the longer term.

Directive clinique no 405 : Dépistage et conseils en matière de consommation d'alcool pendant la grossesse

OBJECTIF

Établir des normes pancanadiennes fondées sur les meilleures données probantes actuelles sur le dépistage et les conseils en matière de consommation d'alcool et de troubles de consommation d'alcool chez les femmes enceintes ou en âge de procréer. PROFESSIONNELS CONCERNéS: Les fournisseurs de soins qui prodiguent des soins aux femmes enceintes et aux femmes en âge procréer.

POPULATION CIBLE

Les femmes enceintes, les femmes en âge de procréer et leurs familles. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, Embase et CENTRAL avec le thème « alcohol use and pregnancy ». Les résultats ont été filtrés de façon à obtenir des publications parues entre 2010 et septembre 2018. Les termes de recherche ont été mis au point à partir des termes du thésaurus de référence biomédicale MeSH et de mots clés, dont les suivants : pre-pregnancy, pregnant, breastfeeding, lactation, female, women, preconception care, prenatal care, fetal alcohol spectrum disorder, prenatal alcohol exposure, drinking behavior, alcohol abstinence, alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol consumption, alcohol abuse, benzodiazepines, disulfiram, naltrexane, acamprosate, ondansetron, topiramate, cyanamide, calcium carbimide, alcohol deterrents, disease management, detoxification, Alcoholics Anonymous, alcohol counselling, harm reduction, pre-pregnancy care, prenatal care, incidence, prevalence, epidemiological monitoring et brief intervention. Les données probantes retenues proviennent d'essais cliniques, d'études observationnelles, de revues de la littérature, d'analyses systématiques et méta-analyses, de lignes directrices et de conférences de consensus. MéTHODES DE VALIDATION: Les auteurs ont rédigé et accepté le contenu et les recommandations de la présente directive. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation) (consulter les tableaux A1 et A2 de l'annexe en ligne). BéNéFICES, RISQUES, COûTS: La mise en œuvre des recommandations de la présente directive à l'aide d'outils de dépistage validés et de stratégies d'intervention brève peut améliorer la capacité des fournisseurs de soins obstétricaux à reconnaître la consommation d'alcool et la consommation problématique d'alcool chez les femmes enceintes ou en âge de procréer. Il est attendu des fournisseurs de soins de santé qu'ils deviennent confiants et compétents en matière de prise en charge et de soutien de ces femmes afin qu'elles puissent avoir la meilleure santé possible et une issue de grossesse optimale. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

Is another public health crisis brewing beneath the COVID-19 pandemic?

Evidence indicates associations between exposure to mass traumatic events and increased alcohol consumption and related harms following the crises. However, there is limited evidence available to inform alcohol policies during such events. In this commentary, we present the range of government actions to control public access to alcohol during the novel coronavirus disease 2019 pandemic in provinces and territories across Canada. Liquor retailers, including both private and government-run retailers, have been designated as essential services in all jurisdictions, operating under an evolving set of rules. From a public health perspective, keeping liquor retailers open during pandemic-related lockdown restrictions is a delicate decision which poses new risks and considerations about the best strategy for minimizing alcohol-related harms. We discuss the need to strike a balance between supplying public access to alcohol, particularly to those living with dependence, and unintentionally sending the message that alcohol is essential in our lives and encouraging consumption. Given the far-reaching effects of alcohol on health, social, psychological, economic, and work safety outcomes, we describe international guidance for minimizing alcohol-related harms and suggest that a nuanced and evidence-informed discussion about the considerations and impacts of alcohol control measures during a public health emergency should be undertaken.

Hippocampal DNA Methylation in a Mouse Model of Fetal Alcohol Spectrum Disorder That Includes Maternal Separation Stress Only Partially Explains Changes in Gene Expression

Fetal alcohol spectrum disorder (FASD) is characterized by developmental and behavioral deficits caused by maternal drinking during pregnancy. Children born with FASD often face additional stresses, including maternal separation, that add yet additional deficits. The mechanism associated with this interaction is not known. We have used a mouse model for prenatal ethanol exposure and maternal separation to demonstrate that the combination of the two treatments results in more than additive deficits. Furthermore, the behavioral deficits are associated with changes in hippocampal gene expression that persist into adulthood. What initiates and maintains these changes remains to be established and forms the focus of this report. Specifically, MeDIP-Seq was used to assess if changes in promoter DNA methylation are affected by exposure to prenatal ethanol and maternal separation including its relationship to gene expression. The novel results show that different sets of genes implicated by promoter DNA methylation are affected by both treatments independently, and a relatively unique set of genes are affected by the combination of the two treatments. Prenatal ethanol exposure leads to altered promoter DNA methylation at genes important for transcriptional regulation. Maternal separation leads to changes at genes important for histone methylation and immune response, and the combination of two treatments results in DNA methylation changes at genes important for neuronal migration and immune response. Our dual results from the same hippocampal samples suggest there is minimal complementarity between changes in promoter DNA methylation and gene expression, although genes involved tend to be critical for brain development and function. While remaining to be validated, such results argue that mechanisms beyond promoter DNA methylation must be involved in lasting gene expression alterations leading to behavioral deficits implicated in FASD. They may facilitate early and reliable diagnosis, as well as novel strategies for the amelioration of FASD-related deficits.

Validation of a hierarchical algorithm to define chronic liver disease and cirrhosis etiology in administrative healthcare data

BACKGROUND AND AIMS

Chronic liver disease (CLD) and cirrhosis are leading causes of death globally with the burden of disease rising significantly over the past several decades. Defining the etiology of liver disease is important for understanding liver disease epidemiology, healthcare planning, and outcomes. The aim of this study was to validate a hierarchical algorithm for CLD and cirrhosis etiology in administrative healthcare data.

METHODS

Consecutive patients with CLD or cirrhosis attending an outpatient hepatology clinic in Ontario, Canada from 05/01/2013-08/31/2013 underwent detailed chart abstraction. Gold standard liver disease etiology was determined by an attending hepatologist as hepatitis C (HCV), hepatitis B (HBV), alcohol-related, non-alcoholic fatty liver disease (NAFLD)/cryptogenic, autoimmune or hemochromatosis. Individual data was linked to routinely collected administrative healthcare data at ICES. Diagnostic accuracy of a hierarchical algorithm incorporating both laboratory and administrative codes to define etiology was evaluated by calculating sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and kappa's agreement.

RESULTS

442 individuals underwent chart abstraction (median age 53 years, 53% cirrhosis, 45% HCV, 26% NAFLD, 10% alcohol-related). In patients with cirrhosis, the algorithm had adequate sensitivity/PPV (>75%) and excellent specificity/NPV (>90%) for all etiologies. In those without cirrhosis, the algorithm was excellent for all etiologies except for hemochromatosis and autoimmune diseases.

CONCLUSIONS

A hierarchical algorithm incorporating laboratory and administrative coding can accurately define cirrhosis etiology in routinely collected healthcare data. These results should facilitate health services research in this growing patient population.