Alcohol licensing legislation and licensing system in South-West Nigeria: Implications to regulate physical availability of alcohol

INTRODUCTION

The proliferation of alcohol outlets has led to increased physical availability of alcohol, harmful alcohol consumption and related harm in Nigeria. This study explored alcohol licensing legislations and licensing systems across local government councils (LGC) in South-West, Nigeria.

METHODS

Twenty-four LGCs across three states participated in the study. Data were generated from: (i) documents containing LGC liquor licensing legislations; and (ii) semi-structured interviews conducted with 50 LGC officials (16 legislative council clerks and 34 finance officers [director of finance, rate officers and revenue collectors]) were thematically analysed using NVivo.

RESULTS

Nine of the sampled LGC enacted liquor licence bylaws. These mostly specified categories of liquor licences issued and licensing fees. None of the liquor licence bylaw contained regulations for controlling physical availability of alcohol and outlet density. Finance officials were licensing officers and there were no licensing committees across the LGCs. The LGC officials were unanimous in stating that generating revenue from licensing fees was the main objective for licensing alcohol outlets. The LGCs licensed alcohol outlets indiscriminately and failed to regulate outlet density.

DISCUSSION AND CONCLUSION

The absence of regulations for controlling outlet density has implications for physical availability of alcohol in Nigeria. Our findings strongly suggest the need to develop national liquor licensing legislation with public health objectives and implementing regulations for controlling temporal and spatial availability of alcohol. Each LGC should inaugurate a licensing committee with clearly defined roles and responsibilities for licensing stakeholders such as LGC health officials, law enforcement agencies and community members.

Alcohol outlet density and marketing in Abeokuta, Nigeria

AIM

The physical availability of alcohol is a modifiable determinant of alcohol consumption and related harm. However, Nigeria currently does not have national regulations restricting the physical availability of alcohol. The study measured alcohol outlet density and marketing in Abeokuta, Nigeria.

METHODS

A descriptive community design was employed. Seven wards in Abeokuta South local government were surveyed street by street for functional alcohol outlets and nearby public institutions (schools and worship centres). Outlet characteristics were documented, and the location of outlets and public institutions was geocoded using a global positioning system app. The density and proximity of outlets and public institutions were analysed using QGIS 3.22.

RESULTS

Four hundred and seventy-six alcohol outlets and 194 public institutions (82 schools, 87 churches, and 25 mosques) were sampled across the 7 wards. The most common type of alcohol premises and outlets was on/off-premises and liquor/non-alcoholic drinks stores. Alcohol banners on liquor store lintels were the most prevalent marketing item. Alcohol outlet density ranged from 8.06 to 200 per km2. The smallest average distance between alcohol outlets was 28 m in Sodeke, while Ago Egun/Ijesa had the highest number of outlets and on/off premises. The shortest distance from an outlet to a school was 18.77 m in Ijaiye and 44 (14.7%) schools were located within ≤100 m of an outlet.

CONCLUSIONS

Findings indicate high alcohol density, resulting in short distances between alcohol outlets and public institutions in Abeokuta South local government area. These results underscore the importance of implementing evidence-based alcohol availability policies in Nigeria.

Psychosocial hazards, posttraumatic stress disorder, complex posttraumatic stress disorder, depression, and anxiety in the U.K. rail industry: A cross-sectional study

This study examined posttraumatic stress disorder (PTSD), complex PTSD, depression, and anxiety among U.K. rail workers. A cross-sectional survey examining exposure to seven psychosocial hazards (bullying/harassment; verbal abuse; physical and sexual assault; and hearing about, seeing the aftermath of, or witnessing a fatality), working conditions, physical health, and the impact of COVID-19 was administered to 3,912 participants. Outcome measures were the ITQ, PHQ-9, and GAD-7. Among trauma-exposed participants, 24.3% met the criteria for PTSD or CPTSD; 38.6% and 29.2% of all participants scored in the moderate-to-severe range on the PHQ-9 and GAD-7, respectively. Data were analyzed using logistic and linear regression. Bullying/harassment was positively associated with GAD-7 scores, f² = .001, and PTSD and CPTSD, ORs = 1.83-2.02. Hearing about and witnessing a fatality were associated with PTSD and CPTSD, ORs = 1.77-2.10. Poorer ergonomics at work were positively associated with PHQ-9 and GAD-7 scores, f² = .001. Higher job satisfaction was associated with lower odds of PTSD and CPTSD, ORs = 0.87-0.91, and negatively associated with PHQ-9 and GAD-7 scores, f² = .008-.01. Work intensity was associated with PTSD and CPTSD, ORs = 1.79-1.83, and positively associated with PHQ-9 and GAD-7 scores, f² = .02-.03. Reporting more physical health problems was associated with PTSD, OR = 1.07, and positively associated with GAD-7 and PHQ-9 scores, f² = .008-.01. The results suggest bullying/harassment and work intensity are important variables in employee mental health and could drive future research and industry initiatives.

Effectiveness and cost-effectiveness of face-to-face and electronic brief interventions versus screening alone to reduce alcohol consumption among high-risk adolescents presenting to emergency departments: three-arm pragmatic randomized trial (SIPS Junior high risk trial)

BACKGROUND AND AIMS

Alcohol use increases throughout adolescence. Emergency department (ED) attendance is an opportunity for alcohol screening and brief intervention (ASBI), which is effective for adults. This trial evaluated the effectiveness and cost-effectiveness of ASBI compared with screening alone (SA) in high-risk adolescents.

DESIGN, SETTING AND PARTICIPANTS

Multi-centre, three-group, single-blind, individually randomized trial with follow-ups after 6 and 12 months in 10 ED settings in England. From October 2014 to May 2015 we screened 3327 adolescents aged 14 to 18 years, of whom 756 (22.7%) scored at least 3 on the Alcohol Use Disorders Identification Test: consumption (AUDIT-C) and consented to participate in this trial. Mean age was 16.1 years; 50.2% were female and 84.9% were white.

INTERVENTIONS

Interventions were personalized feedback and brief advice (PFBA), personalized feedback plus electronic brief intervention (eBI) and SA.

MEASURES

The primary outcome was the weekly alcohol consumed in standard UK units (8 g ethanol) at 12 months post-randomization, derived from extended AUDIT-C. Economic outcomes included quality of life and service use, from perspectives of both the National Health Service and personal social services (NHS&PSS) and society.

FINDINGS

At 12 months, mean weekly consumption was 2.99 [95% confidence interval (CI) = 2.38-3.70] standard units for the SA group, 3.56 (95% CI = 2.90, 4.32) for PFBA and 3.18 (95% CI = 2.50, 3.97) for eBI, showing no significant differences. The PFBA group consumed mean 0.57 (-0.36, 1.70) units more than SA; and eBIs consumed 0.19 (-0.71, 1.30) more. Bayes factors suggested lack of effectiveness explained non-significance. From the NHS&PSS perspective, economic analysis showed that PFBA and eBI were not cost-effective compared with SA: PFBA yielded incremental cost-effectiveness ratio of £6213 (-£736 843, £812 884), with the intervention having 54% probability of being cost-effective compared with SA at the £20 000 WTP threshold.

CONCLUSIONS

In emergency departments in England, neither personalized feedback and brief advice nor personalized feedback plus electronic brief intervention showed evidence of being effective or cost-effective when compared with screening alone in reducing alcohol consumption among adolescents.

Towards establishing a research lineage via identification of significant citations

Finding the lineage of a research topic is crucial for understanding the prior state of the art and advancing scientific displacement. The deluge of scholarly articles makes it difficult to locate the most relevant previous work. It causes researchers to spend a considerable amount of time building up their literature list. Citations play a crucial role in discovering relevant literature. However, not all citations are created equal. The majority of the citations that a paper receives provide contextual and background information to the citing papers. In those cases, the cited paper is not central to the theme of citing papers. However, some papers build upon a given paper and further the research frontier. In those cases, the concerned cited paper plays a pivotal role in the citing paper. Hence, the nature of the citation that the former receives from the latter is significant. In this work, we discuss our investigations towards discovering significant citations of a given paper. We further show how we can leverage significant citations to build a research lineage via a significant citation graph. We demonstrate the efficacy of our idea with two real-life case studies. Our experiments yield promising results with respect to the current state of the art in classifying significant citations, outperforming the earlier ones by a relative margin of 20 points in terms of precision. We hypothesize that such an automated system can facilitate relevant literature discovery and help identify knowledge flow for a particular category of papers.

Exploring the role of psychological need fulfilment on stress, job satisfaction and turnover intention in support staff working in inpatient mental health hospitals in the NHS: a self-determination theory perspective

BACKGROUND

Meeting psychological needs for autonomy, competence and relatedness as described by Self-Determination Theory (SDT) has been associated with increased well-being and job satisfaction in mental health staff and improved care outcomes for patients.

AIMS

The study investigated whether psychological need satisfaction predicted stress, turnover intention and job satisfaction in health care assistants (HCA) working in inpatient mental health hospitals in the United Kingdom including full time (FT) and temporary agency worker (TAW) staff.

METHODS

A cross-sectional survey explored need satisfaction between FT (n = 63) and TAW (n = 39) staff using the Work-Related Basic Need Satisfaction Scale. Multiple regression was used to explore whether satisfaction of the needs for autonomy, competence and relatedness predicted scores on measures of stress, job satisfaction and turnover intention.

RESULTS

Results were comparable between FT and TAW staff. Autonomy was the need least satisfied, a need which predicted self-reported job satisfaction, stress and turnover intention. Relatedness also predicted job satisfaction and turnover intention.

CONCLUSIONS

Recommendations are made to explore experiences of (and barriers to) autonomy and relatedness in inpatient HCA staff to target and improve autonomy and relatedness in this workforce. Implications of doing so are considered at a staffing, organisational and patient level.

Brief interventions to prevent excessive alcohol use in adolescents at low-risk presenting to Emergency Departments: Three-arm, randomised trial of effectiveness and cost-effectiveness

BACKGROUND

Alcohol consumption and related harm increase rapidly from the age of 12 years. We evaluated whether alcohol screening and brief intervention is effective and cost-effective in delaying hazardous or harmful drinking amongst low-risk or abstaining adolescents attending Emergency Departments (EDs).

METHODS

This ten-centre, three-arm, parallel-group, single-blind, pragmatic, individually randomised trial screened ED attenders aged between 14 and 17 years for alcohol consumption. We sampled at random one third of those scoring at most 2 on AUDIT-C who had access to the internet and, if aged under 16, were Gillick competent or had informed consent from parent or guardian. We randomised them between: screening only (control intervention); one session of face-to-face Personalised Feedback and Brief Advice (PFBA); and PFBA plus an electronic brief intervention (eBI) on smartphone or web. We conducted follow-up after six and 12 months. The principal outcomes were alcohol consumed over the 3 months before 12-month follow up, measured by AUDIT-C; and quality-adjusted life-years.

FINDINGS

Between October 2014 and May 2015, we approached 5,016 eligible patients of whom 3,326 consented to be screened and participate in the trial; 2,571 of these were low-risk drinkers or abstainers, consuming an average 0.14 units per week. We randomised: 304 to screening only; 285 to PFBA; and 294 to PFBA and eBI. We found no significant difference between groups, notably in weekly alcohol consumption: those receiving screening only drank 0.10 units (95% confidence interval 0.05 to 0.18); PFBA 0.12 (0.06 to 0.21); PFBA and eBI 0.10 (0.05 to 0.19).

INTERPRETATION

While drinking levels remained low in this population, this trial found no evidence that PFBA with or without eBI was more effective than screening alone in reducing or delaying alcohol consumption.

Khat and neurobehavioral functions: A systematic review

Background

Khat is a plant that is used for its amphetamine-like stimulant properties. However, although khat is very popular in Eastern Africa, Arabian Peninsula, and the Middle East, there is still a lack of studies researching the possible neurobehavioral impairment derived from khat use.

Methods

A systematic review was conducted to identify studies that assessed the effects of khat use on neurobehavioral functions. MedLine, Scopus, Cochrane, Web of Science and Open Grey literature were searched for relevant publications from inception to December 2020. Search terms included (a) khat and (b) several cognitive domains. References from relevant publications and grey literature were also reviewed to identify additional citations for inclusion.

Results

A total of 142 articles were reviewed, 14 of which met the inclusion criteria (nine human and five rodent studies). Available human studies suggest that long term khat use is associated with significant deficits in several cognitive domains, including learning, motor speed/coordination, set-shifting/response inhibition functions, cognitive flexibility, short term/working memory, and conflict resolution. In addition, rodent studies indicated daily administration of khat extract resulted in dose-related impairments in behavior such as motor hyperactivity and decreased cognition, mainly learning and memory.

Conclusions

The findings presented in this review indicates that long-term khat use may be contributing to an impairment of neurobehavioral functions. However, gaps in literature were detected that future studies could potentially address to better understand the health consequences of khat use.

Alcohol Labeling Regulations and Industry Compliance in Nigeria: Evidence to Guide Policy Implementation

OBJECTIVE

Alcohol labeling raises consumers' awareness of a product's composition and the risks associated with alcohol consumption. We identified mandatory elements and health warnings in alcohol regulations in Nigeria and evaluated selected product labels on alcoholic beverages produced in Nigeria to determine their compliance with the requirements.

METHOD

A descriptive case study was used. Labeling requirements were extracted from two alcohol regulations and one related document retrieved from the website of the National Agency for Food and Drug Administration and Control (NAFDAC). The information on the product labels of 59 selected beers and spirit drinks produced in Nigeria was assessed based on six mandatory elements: list of ingredients, allergens, nutritional information, percentage of alcohol by volume (ABV), "drink responsibly" statement, and age restrictions. Five health warnings were also assessed: standard drinks per container, drinking guidelines, link to an alcohol education website, a "drinking during pregnancy" logo/text, and drink driving logo/text.

RESULTS

Different regulations exist for beer and spirit drinks in Nigeria. Health warnings are not mandatory on labels of alcoholic beverages. No single product label included all six mandatory elements. Four mandatory elements--list of ingredients, ABV, drink responsibly statement, and age restrictions--were present on 61% of the product labels examined.

CONCLUSIONS

The alcohol labeling regulations in Nigeria fall short of the World Health Organization labeling recommendations. The alcohol industry does not fully comply with labeling requirements in Nigeria. Enhanced labeling inclusive of health warnings should be mandatory as a strategy to create awareness of alcohol-related risks while monitoring industry-labeling practices to ensure compliance.

A biobank analysis of prognostic biomarkers of the systemic inflammatory response in patients presenting with malignancy of undefined primary origin

BACKGROUND

Survival prediction in patients presenting with malignancy of undefined primary origin (MUO) is challenging, with a lack of validated prognostic tools. Biomarkers of the systemic inflammatory response independently predict survival in other cancer types, but their role in MUO is unclear. The aim of this study was to assess biomarkers of the systemic inflammatory response in patients presenting with MUO.

PATIENTS AND METHODS

A biobank of 1049 patients presenting with MUO referred to a regional oncology service in Scotland was analysed. Key inflammatory biomarkers (white cell count, neutrophil count and C-reactive protein combined with albumin [to give the modified Glasgow Prognostic Score {mGPS}]) were examined. The relationship between these and survival was examined using Kaplan-Meier and Cox regression methods.

RESULTS

Data were available for 1049 patients. Median survival was 4.3 months (interquartile range: 1.7-16.0 months). On multivariate analysis mGPS was independently associated with survival and stratified survival from 13.6 months (mGPS: 0) to 2.3 months (mGPS: 2) (p < 0.001). The mGPS was predictive of survival on multivariate analysis in patients found to have a non-cancer diagnosis (p = 0.034), an identified primary cancer (0.002), cancer of unknown primary (CUP) (p = 0.011), those for whom biopsy was not done (MUO) (p = 0.036), those found to have an identified primary cancer (0.002) and even those found to have a non-cancer diagnosis (p = 0.034) after further detailed investigations. In patients with CUP mGPS predicted survival regardless of the recognised clinicopathological prognostic subgroup (p < 0.001).

CONCLUSIONS

The results of the present study demonstrate that biomarkers of the systemic inflammatory response are reliable prognostic factors in patients presenting with MUO. These simple, objective, routine clinical tests may inform clinical management.

The impact of multiple chemical sensitivity on people's social and occupational functioning; a systematic review of qualitative research studies

OBJECTIVE

Social and occupational functioning are important for psychological health. However, quantitative research has suggested that these areas can be adversely affected by multiple chemical sensitivity (MCS). This systematic review therefore sought to explore what qualitative research has suggested about how people with MCS perceive it to affect their social and occupational functioning.

METHOD

Journal articles were included if they were 1) peer reviewed 2) qualitative or mixed methods 3) published in English 4) reported qualitative findings relevant to the review. Studies were excluded if they were 1) descriptive only 2) primarily concerned with environmental intolerances other than chemicals or 3) focussed on specific populations such as veterans. Quality was assessed using the National Institute for Health and Care Excellence (NICE, 2018) qualitative quality criteria. However, quality was not used to determine eligibility for inclusion. Six databases (CINAHL, Medline, PsychArticles, PsychInfo, Scopus and Web of Science) were searched between the 24th of February 2019 and 2nd of March 2019.

RESULTS

Having removed duplicates, database searches identified 388 potential articles. Thirteen of these articles were eligible for inclusion. Following review, no more articles were included from the reference lists of these studies. Meta-aggregation of the findings identified seven categories. These were synthesised into three themes; 'limited access', 'loss & anxiety' and 'seeking engagement'.

CONCLUSIONS

The findings suggested that MCS limits some people's social and occupational functioning. The results warrant further research, and, the development of prevention and intervention strategies. Studies predominantly recruited United States and Canadian females and had several limitations.

Screening and brief interventions for adolescent alcohol use disorders presenting through emergency departments: a research programme including two RCTs

Background

Alcohol consumption and related harm increase steeply from the ages of 12–20 years. Adolescents in the UK are among the heaviest drinkers in Europe. Excessive drinking in adolescents is associated with increased risk of accidents, injuries, self-harm, unprotected or regretted sex, violence and disorder, poisoning and accidental death. However, there is lack of clear evidence for the most clinically effective and cost-effective screening and brief interventions for reducing or preventing alcohol consumption in adolescents attending emergency departments (EDs).

Objectives

To estimate the distribution of alcohol consumption, alcohol-related problems and alcohol use disorders in adolescents attending EDs; to develop age-appropriate alcohol screening and brief intervention tools; and to evaluate the clinical effectiveness and cost-effectiveness of these interventions.

Design

The research has been conducted in three linked stages: (1) a prevalence study, (2) intervention development and (3) two linked randomised controlled trials (RCTs).

Setting

Twelve EDs in England (London, North East, and Yorkshire and The Humber).

Participants

A total of 5376 participants in the prevalence study [mean age 13.0 years, standard deviation (SD) 2.0 years; 46.2% female] and 1640 participants in the two linked RCTs (mean age 15.6 years, SD 1.0 years; 50.7% female).

Interventions

Personalised feedback and brief advice (PFBA) and personalised feedback plus electronic brief intervention (eBI), compared with alcohol screening alone. These age-appropriate alcohol interventions were developed in collaboration with the target audience through a series of focus groups and evaluations during stage 2 of the research programme and following two literature reviews.

Main outcome measures

Total alcohol consumed in standard UK units (1 unit = 8 g of ethanol) over the previous 3 months at 12-month follow-up, assessed using the Alcohol Use Disorders Identification Test, Consumption (3 items) (AUDIT-C).

Results

In the prevalence study, 2112 participants (39.5%) reported having had a drink of alcohol that was more than a sip in their lifetime, with prevalence increasing steadily with age and reaching 89.5% at the age of 17 years. The prevalence of at-risk alcohol consumption was 15% [95% confidence interval (CI) 14% to 16%] and the optimum cut-off point of the AUDIT-C in identifying at-risk drinking was ≥ 3. Associations of alcohol consumption and early onset of drinking with poorer health and social functioning were also found. In the RCT, the analysis of the primary outcome (average weekly alcohol consumption at month 12) identified no significant differences in effect between the three groups in both trials. In the high-risk drinking trial, the mean difference compared with control was 0.57 (95% CI –0.36 to 1.70) for PFBA and 0.19 (95% CI –0.71 to 1.30) for eBI. In the low-risk drinking trial, the mean difference compared with control was 0.03 (95% CI –0.07 to 0.13) for PFBA and 0.01 (95% CI –0.10 to 0.11) for eBI. The health economic analysis showed that eBI and PFBA were not more cost-effective than screening alone.

Conclusions

The ED can offer an opportunity for the identification of at-risk alcohol use in adolescents. A simple, short, self-completed screening instrument, the AUDIT-C, is an effective tool for identifying adolescents who are at risk of alcohol-related problems. Associations of alcohol consumption and earlier onset of drinking with poorer health and social functioning were observed in the prevalence study. The trials were feasible to implement and exceeded the recruitment target and minimum follow-up rates. However, PFBA and eBI were not found to be more effective than screening alone in reducing or preventing alcohol consumption in 14- to 17-year-olds attending EDs.

Limitations and future work

Only one-third of participants engaged with the application program; this is likely to have limited the effect of the intervention. We recommend that future research should focus on methods to maximise engagement with digital interventions and evaluate the effect of such engagement on clinical outcomes.

Trial registration

Current Controlled Trials ISRCTN45300218.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 2. See the NIHR Journals Library website for further project information.

Adolescent perspectives about their participation in alcohol intervention research in emergency care: A qualitative exploration using ethical principles as an analytical framework

AIMS

To explore adolescents' experiences of consenting to, and participating in, alcohol intervention trials when attending for emergency care.

METHODS

In-depth semi-structured interviews with 27 adolescents (16 males; aged 14-17 years (Mage = 15.7)) who had taken part in one of two linked brief alcohol intervention trials based in 10 accident and emergency departments in England. Interviews were transcribed verbatim and subject to thematic analysis.

RESULTS

Research and intervention methods were generally found to be acceptable though confidentiality was important and parental presence could hinder truthful disclosures regarding alcohol use. Participants discussed the importance of being involved in research that was relevant to them and recognised alcohol consumption as a normative part of adolescence, highlighting the importance of having access to appropriate health information. Beyond this, they recognised the benefits and risks of trial participation for themselves and others with the majority showing a degree of altruism in considering longer term implications for others as well as themselves.

CONCLUSIONS

Alcohol screening and intervention in emergency care is both acceptable and relevant to adolescents but acceptability is reliant on confidentiality being assured and may be inhibited by parental presence.

TRIAL REGISTRATION

ISRCTN Number: 45300218.

Opportunistic screening for alcohol use problems in adolescents attending emergency departments: an evaluation of screening tools

Objective

To estimate and compare the optimal cut-off score of Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C in identifying at-risk alcohol consumption, heavy episodic alcohol use, ICD-10 alcohol abuse and alcohol dependence in adolescents attending ED in England.

Design

Opportunistic cross-sectional survey.

Setting

10 emergency departments across England.

Participants

Adolescents (n = 5377) aged between their 10th and 18th birthday who attended emergency departments between December 2012 and May 2013.

Measures

Scores on the AUDIT and AUDIT-C. At-risk alcohol consumption and monthly episodic alcohol consumption in the past 3 months were derived using the time-line follow back method. Alcohol abuse and alcohol dependence was assessed in accordance with ICD-10 criteria using the MINI-KID.

Findings

AUDIT-C with a score of 3 was more effective for at-risk alcohol use (AUC 0.81; sensitivity 87%, specificity 97%), heavy episodic use (0.84; 76%, 98%) and alcohol abuse (0.98; 91%, 90%). AUDIT with a score of 7 was more effective in identifying alcohol dependence (0.92; 96%, 94%).

Conclusions

The 3-item AUDIT-C is more effective than AUDIT in screening adolescents for at-risk alcohol use, heavy episodic alcohol use and alcohol abuse. AUDIT is more effective than AUDIT-C for the identification of alcohol dependence.

Screening for At-Risk Alcohol Consumption in Primary Care: A Randomized Evaluation of Screening Approaches

Aims

The aim of the study was to explore the relative efficiency and effectiveness of targeted versus universal screening for at-risk alcohol use in a primary care population in the UK.

Methods

The study was a randomized evaluation of screening approach (targeted versus universal) for consecutive attendees at primary care aged 18 years or more. Targeted screening involved screening any patient attending with one of the targeted presentations, conditions associated with excessive alcohol consumption: mental health, gastrointestinal, hypertension, minor injuries or a new patient registration. In the universal arm of the study all presentations in the recruitment period were included. Universal screening included all patients presenting to allocated practices.

Results

A total of 3562 potential participants were approached. The odds ratio of being screen positive was higher for the targeted group versus the universal group. Yet the vast majority of those screening positive in the universal group of the study would have been missed by a targeted approach. A combination of age and gender was a more efficient approach than targeting by clinical condition or context.

Conclusions

While screening targeted by age and gender is more efficient than universal screening, targeting by clinical condition or presentation is not. Further universal screening is more effective in identifying the full range of patients who could benefit from brief alcohol interventions, and would therefore have greater public health impact.

Trial registration

Current Controlled Trials ISRCTN06145674.

Adiabatic Quantum Computation Applied to Deep Learning Networks

Training deep learning networks is a difficult task due to computational complexity, and this is traditionally handled by simplifying network topology to enable parallel computation on graphical processing units (GPUs). However, the emergence of quantum devices allows reconsideration of complex topologies. We illustrate a particular network topology that can be trained to classify MNIST data (an image dataset of handwritten digits) and neutrino detection data using a restricted form of adiabatic quantum computation known as quantum annealing performed by a D-Wave processor. We provide a brief description of the hardware and how it solves Ising models, how we translate our data into the corresponding Ising models, and how we use available expanded topology options to explore potential performance improvements. Although we focus on the application of quantum annealing in this article, the work discussed here is just one of three approaches we explored as part of a larger project that considers alternative means for training deep learning networks. The other approaches involve using a high performance computing (HPC) environment to automatically find network topologies with good performance and using neuromorphic computing to find a low-power solution for training deep learning networks. Our results show that our quantum approach can find good network parameters in a reasonable time despite increased network topology complexity; that HPC can find good parameters for traditional, simplified network topologies; and that neuromorphic computers can use low power memristive hardware to represent complex topologies and parameters derived from other architecture choices.

Alcohol identification and intervention in English emergency departments

AIMS

In the ED, alcohol identification and brief advice is an effective method of reducing consumption and related harms. Our objective was to conduct a national survey of English EDs to determine current practice regarding alcohol identification and provision of brief advice and to compare changes in activity to a previous National Survey conducted in 2011.

METHODS

This was a cross-sectional survey of all consultant-led EDs in England.

RESULTS

Of 180 departments, 147 (81.6%) responded. All departments may question adult patients about their alcohol consumption, with many (63.6%) asking all patients aged over 18 years as part routine care and using a formal screening tool (61.4%). The majority of departments asked young people (aged 11-17 years) about their consumption (83.8%), but only 11.6% did so as a part of routine practice. Compared with the 2011 survey, there have been significant increases in routine screening among adults (15.9%, CI 4.16% to 27.18%; p=0.006), general practitioners being informed about patients'alcohol-related presentations (10.2%, CI 0.64% to 19.58%; p=0.028) and access to an alcohol health worker or a clinical nurse specialist (13.4%, CI 3.64% to 22.91%, p=0.005). Modest (non-significant) changes were also found in access to training on brief advice (9.7%) and the use of formal screening questions on adult patients (9.7%).

CONCLUSION

Alcohol screening together with referral or intervention is becoming part of routine practice in England. Compared with our previous national survey, increases in alcohol screening and intervention activity are demonstrated, with improvements in routine questioning (among adults), the number of general practitioners being informed about alcohol-related attendances, provision of training, access to specialist services and the use of formal screening tools.

Alcohol Consumption, Early-Onset Drinking, and Health-Related Consequences in Adolescents Presenting at Emergency Departments in England

PURPOSE

Globally, alcohol use is the leading cause of ill health and life years lost in adolescents, although its clinical impact is often overlooked, particularly in England where most research is based in schools. This study aims to examine the prevalence of alcohol consumption and the association between alcohol consumption and age of onset with health and social consequences among adolescents presenting to emergency departments (EDs).

METHODS

Consecutive attenders (n = 5,576) aged 10-17 years at 10 EDs were included. Information was collected on general health and functioning, quality of life, alcohol use, and alcohol-related health and social consequences.

RESULTS

Nearly 40% of adolescents reported the consumption of alcohol that was more than a sip in their lifetime. Age of the first alcohol consumption before the age of 15 years was associated with tobacco use (p < .001), lower quality of life (p = .003), and evidence of an alcohol use disorder (p = .002). It was also associated with general social functioning (problems with conduct p = .001 and hyperactivity p = .001) and alcohol-related health and social consequences (accident p = .046, problems with a parent p = .017, school p = .0117, or police p = .012).

CONCLUSIONS

Rates of alcohol consumption in adolescents presenting to the ED were similar to those reported in schools in England and globally. Associations of alcohol consumption and earlier onset of drinking with poorer health and social functioning were observed. The ED can offer an opportunity for the identification of hazardous alcohol use in adolescents.

Commentary on Bertholet et al. (2015): Proceed, with caution

Internet-based interventions can reach large numbers of those in need of help and advice about their drinking and reduce levels of consumption. While many systematic reviews suggest that this is a useful mechanism to promote behavioural change, the effective components are unclear. User involvement is needed for effective design.

Linked randomised controlled trials of face-to-face and electronic brief intervention methods to prevent alcohol related harm in young people aged 14-17 years presenting to Emergency Departments (SIPS junior)

BACKGROUND

Alcohol is a major global threat to public health. Although the main burden of chronic alcohol-related disease is in adults, its foundations often lie in adolescence. Alcohol consumption and related harm increase steeply from the age of 12 until 20 years. Several trials focusing upon young people have reported significant positive effects of brief interventions on a range of alcohol consumption outcomes. A recent review of reviews also suggests that electronic brief interventions (eBIs) using internet and smartphone technologies may markedly reduce alcohol consumption compared with minimal or no intervention controls. Interventions that target non-drinking youth are known to delay the onset of drinking behaviours. Web based alcohol interventions for adolescents also demonstrate significantly greater reductions in consumption and harm among 'high-risk' drinkers; however changes in risk status at follow-up for non-drinkers or low-risk drinkers have not been assessed in controlled trials of brief alcohol interventions.

DESIGN AND METHODS

The study design comprises two linked randomised controlled trials to evaluate the effectiveness and cost-effectiveness of two intervention strategies compared with screening alone. One trial will focus on high-risk adolescent drinkers attending Emergency Departments (Eds) and the other will focus on those identified as low-risk drinkers or abstinent from alcohol but attending the same ED. Our primary (null) hypothesis is similar for both trials: Personalised Feedback and Brief Advice (PFBA) and Personalised Feedback plus electronic Brief Intervention (eBI) are no more effective than screening alone in alcohol consumed at 12 months after randomisation as measured by the Time-Line Follow-Back 28-day version. Our secondary (null) hypothesis relating to economics states that PFBA and eBI are no more cost-effective than screening alone. In total 1,500 participants will be recruited into the trials, 750 high-risk drinkers and 750 low-risk drinkers or abstainers. Participants will be randomised with equal probability, stratified by centre, to either a screening only control group or one of the two interventions: single session of PFBA or eBI. All participants will be eligible to receive treatment as usual in addition to any trial intervention. Individual participants will be followed up at 6 and 12 months after randomisation.

DISCUSSION

The protocol represents an ambitious innovative programme of work addressing alcohol use in the adolescent population.

TRIAL REGISTRATION

ISRCTN45300218. Registered 5th July 2014.

The association between shame and substance use in young people: a systematic review

Background. Shame has been associated with a range of maladaptive behaviours, including substance use. Young people may be particularly vulnerable to heightened shame sensitivity, and substance use is a significant problem amongst UK adolescents. Although there appears to be a relationship between shame and substance use, the direction of the relationship remains unclear.

Aim. The purpose of this study was to undertake a systematic review of the literature relating to shame and substance use in young people.

Method. Five electronic databases were searched for articles containing terms related to ‘adolescence,’ ‘shame’ and ‘substance use.’ Six articles were included in the final analyses.

Results. Adverse early experiences, particularly sexual abuse, predict shame-proneness, and substance use is a mechanism by which some individuals cope with negative feelings. In general, there is a dearth of literature investigating the shame-substance use relationship in adolescent samples. The available literature associates shame-proneness with poorer functioning and suggests that it may potentially lead to psychopathology and early-onset substance use. Scant attention has been paid to the cognitive and emotional processes implicated. Further research is required to ascertain the strength of the shame-substance use relationship in young people and to develop appropriate interventions for this population.

Replacement of Promethazine With Ondansetron for Treatment of Opioid- and Trauma-Related Nausea and Vomiting in Tactical Combat Casualty Care

The current Tactical Combat Casualty Care (TCCC) Guidelines recommend parenteral promethazine as the single agent for the treatment of opioid-induced nausea and/or vomiting and give a secondary indication of "synergistic analgesic effect." Promethazine, however, has a well-documented history of undesired side effects relating to impairment and dysregulation of the central and autonomic nervous systems, such as sedation, extrapyramidal symptoms, dystonia, impairment of psychomotor function, neuroleptic malignant syndrome, and hypotension. These may be particularly worrisome in the combat casualty. Additionally, since 16 September 2009, there has been a US Food and Drug Administration (FDA) black box warning for the injectable form of promethazine, due to "the risk of serious tissue injury when this drug is administered incorrectly." Conversely, ondansetron, which is now available in generic form, has a well-established favorable safety profile and demonstrated efficacy in undifferentiated nausea and vomiting in the emergency department and prehospital settings. It has none of the central and autonomic nervous system side effects noted with promethazine and carries no FDA black box warning. Ondansetron is available in parenteral form and an orally disintegrating tablet, providing multiple safe and effective routes of administration. Despite the fact that it is an off-label use, ondansetron is being increasingly given for acute, undifferentiated nausea and vomiting and is presently being used in the field on combat casualties by some US and Allied Forces. Considering the risks involved with promethazine use, and the efficacy and safety of ondansetron and ondansetron?s availability in a generic form, we recommend removing promethazine from the TCCC Guidelines and replacing it with ondansetron.

Alcohol screening and brief interventions for offenders in the probation setting (SIPS Trial): a pragmatic multicentre cluster randomized controlled trial

AIM

To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in the probation setting. Offender managers were randomized to three interventions, each of which built on the previous one: feedback on screening outcome and a client information leaflet control group, 5 min of structured brief advice and 20 min of brief lifestyle counselling.

METHODS

A pragmatic multicentre factorial cluster randomized controlled trial. The primary outcome was self-reported hazardous or harmful drinking status measured by Alcohol Use Disorders Identification Test (AUDIT) at 6 months (negative status was a score of <8). Secondary outcomes were AUDIT status at 12 months, experience of alcohol-related problems, health utility, service utilization, readiness to change and reduction in conviction rates.

RESULTS

Follow-up rates were 68% at 6 months and 60% at 12 months. At both time points, there was no significant advantage of more intensive interventions compared with the control group in terms of AUDIT status. Those in the brief advice and brief lifestyle counselling intervention groups were statistically significantly less likely to reoffend (36 and 38%, respectively) than those in the client information leaflet group (50%) in the year following intervention.

CONCLUSION

Brief advice or brief lifestyle counselling provided no additional benefit in reducing hazardous or harmful drinking compared with feedback on screening outcome and a client information leaflet. The impact of more intensive brief intervention on reoffending warrants further research.

The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

Background

Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial.

Methods and Findings

Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings.

Conclusions

SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions.

Trial Registration

Current Controlled Trials ISRCTN 93681536

The effectiveness of electronic screening and brief intervention for reducing levels of alcohol consumption: a systematic review and meta-analysis

BACKGROUND

Electronic screening and brief intervention (eSBI) has been shown to reduce alcohol consumption, but its effectiveness over time has not been subject to meta-analysis.

OBJECTIVE

The current study aims to conduct a systematic review and meta-analysis of the available literature to determine the effectiveness of eSBI over time in nontreatment-seeking hazardous/harmful drinkers.

METHODS

A systematic review and meta-analysis of relevant studies identified through searching the electronic databases PsychINFO, Medline, and EMBASE in May 2013. Two members of the study team independently screened studies for inclusion criteria and extracted data. Studies reporting data that could be transformed into grams of ethanol per week were included in the meta-analysis. The mean difference in grams of ethanol per week between eSBI and control groups was weighted using the random-effects method based on the inverse-variance approach to control for differences in sample size between studies.

RESULTS

There was a statistically significant mean difference in grams of ethanol consumed per week between those receiving an eSBI versus controls at up to 3 months (mean difference -32.74, 95% CI -56.80 to -8.68, z=2.67, P=.01), 3 to less than 6 months (mean difference -17.33, 95% CI -31.82 to -2.84, z=2.34, P=.02), and from 6 months to less than 12 months follow-up (mean difference -14.91, 95% CI -25.56 to -4.26, z=2.74, P=.01). No statistically significant difference was found at a follow-up period of 12 months or greater (mean difference -7.46, 95% CI -25.34 to 10.43, z=0.82, P=.41).

CONCLUSIONS

A significant reduction in weekly alcohol consumption between intervention and control conditions was demonstrated between 3 months and less than 12 months follow-up indicating eSBI is an effective intervention.

Alcohol screening and brief intervention for adolescents: the how, what and where of reducing alcohol consumption and related harm among young people

AIM

The aim of the study was to explore the evidence base on alcohol screening and brief intervention for adolescents to determine age appropriate screening tools, effective brief interventions and appropriate locations to undertake these activities.

METHODS

A review of existing reviews (2003-2013) and a systematic review of recent research not included in earlier reviews.

RESULTS

The CRAFFT and AUDIT tools are recommended for identification of 'at risk' adolescents. Motivational interventions delivered over one or more sessions and based in health care or educational settings are effective at reducing levels of consumption and alcohol-related harm.

CONCLUSION

Further research to develop age appropriate screening tools needs to be undertaken. Screening and brief intervention activity should be undertaken in settings where young people are likely to present; further assessment at such venues as paediatric emergency departments, sexual health clinics and youth offending teams should be evaluated. The use of electronic (web/smart-phone based) screening and intervention shows promise and should also be the focus of future research.

Clostridium perfringens bacteremia caused by choledocholithiasis in the absence of gallbladder stones

A 67-years-old male presented with periumbilical abdominal pain, fever and jaundice. His anaerobic blood culture was positive for clostridium perfringens. Computed tomogram scan of the abdomen and abdominal ultrasound showed normal gallbladder and common bile duct (CBD). Subsequently magnetic resonance cholangiopancreaticogram showed choledocholithiasis. Endoscopic retrograde cholangiopancreaticogramwith sphincterotomy and CBD stone extraction was performed. The patient progressively improved with antibiotic therapy Choledocholithiasis should be considered as a source of clostridium perfringens bacteremia especially in the setting of elevated liver enzymes with cholestatic pattern.

Tobacco carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone initiates and enhances pancreatitis responses

Clinical studies indicate that cigarette smoking increases the risk for developing acute pancreatitis. The nicotine metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is a major cigarette smoke toxin. We hypothesized that NNK could sensitize to pancreatitis and examined its effects in isolated rat pancreatic acini and in vivo. In acini, 100 nM NNK caused three- and fivefold activation of trypsinogen and chymotrypsinogen, respectively, above control. Furthermore, NNK pretreatment in acini enhanced zymogen activation in a cerulein pancreatitis model. The long-term effects of NNK were examined in vivo after intraperitoneal injection of NNK (100 mg/kg body wt) three times weekly for 2 wk. NNK alone caused zymogen activation (6-fold for trypsinogen and 2-fold for chymotrypsinogen vs. control), vacuolization, pyknotic nuclei, and edema. This NNK pretreatment followed by treatment with cerulein (40 μg/kg) for 1 h to induce early pancreatitis responses enhanced trypsinogen and chymotrypsinogen activation, as well as other parameters of pancreatitis, compared with cerulein alone. Potential targets of NNK include nicotinic acetylcholine receptors and β-adrenergic receptors; mRNA for both receptor types was detected in acinar cell preparations. Studies with pharmacological inhibitors of these receptors indicate that NNK can mediate acinar cell responses through an nonneuronal α(7)-nicotinic acetylcholine receptor (α(7)-nAChR). These studies suggest that prolonged exposure to this tobacco toxin can cause pancreatitis and sensitize to disease. Therapies targeting NNK-mediated pathways may prove useful in treatment of smoking-related pancreatitis.

Alcohol: signs of improvement. The 2nd national Emergency Department survey of alcohol identification and intervention activity

OBJECTIVES

To conduct a survey of current alcohol identification and brief advice activity in English Emergency Departments, and to compare the results with the previous survey conducted in 2007.

METHODOLOGY

Cross-sectional survey of all 187 Emergency Departments in England.

RESULTS

Significant increases (p<0.001) in the proportion of departments routinely asking about alcohol, using a screening questionnaire, offering help/advice for alcohol problems, and having access to Alcohol Health Workers or Clinical Nurse Specialists. More than half of all departments indicated that they had an 'alcohol champion', and this was significantly associated with access to training on both identification and provision of brief advice (p<0.001). Departments that routinely asked questions were the most likely to use a formal screening tool (p<0.05), and the Paddington Alcohol Test was the most frequently used measure (40.5%).

CONCLUSIONS

There have been significant improvements in ED alcohol identification and brief advice activity since 2007 in line with the recommendations of the Royal College of Physicians, Department of Health and NICE guidelines. English EDs are beginning to maximise the likelihood of identifying patients who may benefit from further help or advice about their alcohol consumption, and are able to offer access to specialist staff who can provide appropriate interventions.

A dose-response study in animals to evaluate the anticoagulant effect of the stage 2 unfractionated heparin USP monograph change

The United States Pharmacopeia (USP) monograph for unfractionated heparin (UFH) was revised in October 2009. This revision was anticipated, based upon in vitro tests, to reduce UFH potency by approximately 10%. To study the potential in vivo consequences of the monograph change, we evaluated activated partial thromboplastin time (aPTT) and activated clotting time (ACT) responses in animals. Female mini-pigs and monkeys (n=8/species) were administered intravenously 60, 54, 48, or 42 U/kg and 50, 45, 40, or 35 U/kg "old" (pre-USP revision) UFH, respectively, in a Williams 4×4 crossover design. Blood samples for aPTT and ACT were collected at 15 min after dosing. The same study design was then repeated using "new" (post-USP revision) UFH. Mean "new" UFH aPTT and ACT values were generally lower than those for "old" UFH although individual animal responses varied considerably. The aPTT and ACT response was generally dose-proportional for both "old" and "new" UFH. These studies indicate that the USP monograph alteration for UFH may result in a modest reduction in the anticoagulant response across a population, but the variability in animal responses underscores the importance of individualization of clinical UFH dosing and the importance of anticoagulant test monitoring.

Efficacy of alcohol screening in the accident and emergency department managed by reception staff: a pilot study

Hazardous levels of alcohol consumption are associated with presentations to the accident and emergency department. Although screening and brief interventions are effective at reducing levels of hazardous drinking, a low number of departments has implemented such a strategy. Time constraints upon clinical staff have been cited as one reason for this inertia. This pilot study demonstrates that self-completion of screening materials is possible before a patient is seen by clinical staff.