Routine outcome monitoring and feedback in alcohol and other drug treatment: A qualitative study of client perspectives on implementation.

INTRODUCTION: Routine outcome monitoring (ROM) and feedback is an evidence-supported strategy for evaluating alcohol and other drug (AOD) treatment outcomes. However, the implementation of ROM and feedback into AOD services remains a significant challenge. Research aimed at understanding client perspectives on ROM and feedback is needed to facilitate successful implementation. This study examined experiences with and perceptions of ROM and feedback in a sample of clients receiving AOD treatment. METHODS: Interviews and online surveys were conducted with N = 26 people (13 male; Mage = 36.12 years, SD = 10.29) enrolled in an AOD treatment program in Australia. Data analysis of the transcripts was guided by thematic analysis, while descriptive statistics were used to analyse quantitative survey data. RESULTS: Four major themes were identified in the qualitative data: (i) ROM and feedback is valuable to AOD treatment; (ii) clear and concise outcome measures with an integrated feedback loop are vital to reliable ROM; (iii) desire for visual and verbal feedback that highlights progress; and (iv) ROM and feedback can be emotionally challenging. DISCUSSION AND CONCLUSIONS: Participants valued ROM when it was clearly integrated within AOD treatment and they received feedback on their responses. Potential facilitators to implementing and improving the provision of ROM and feedback in AOD treatment include: (i) a clear, treatment-based rationale to foster client buy-in for ROM and maximise AOD treatment benefit; (ii) brief outcome measure surveys; and (iii) graphical visualisations of ROM feedback.

Wastewater-based evaluation of the efficacy of oxycodone regulations in Australia.

BACKGROUND AND AIMS: Between 2018 and 2020, Australia implemented major policy changes to improve the quality and safety of opioid prescribing, with a specific focus on oxycodone. This study used wastewater-based epidemiology to assess the efficacy of Australia's regulatory reforms by measuring change in consumption of oxycodone via exploratory analysis. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS: Wastewater analysis data on oxycodone consumption was from the National Wastewater Drug Monitoring Program. The program captures data from more than 50 wastewater treatment plant catchments across Australia, equivalent to more than 50% of the national population. Geographic trend analyses were conducted for both major cities and regional areas within all states and territories of Australia over a 6-year period between 2017 and 2023. FINDINGS: Oxycodone consumption showed a statistically significant increase nationally from 78 mg/day/1000 people (95% confidence interval [CI] = 71, 84) in 2017 to 120 mg/day/1000 people in August 2019 (95% CI = 110, 120), an increase of 52% (95% CI = 42, 62, P < 0.0001). From August 2019 to December 2020, there was a statistically significant decrease from 120 to 65 mg/day/1000 people (95% CI = 60, 71), a decrease of 45% (95% CI = 40, 51), followed by a modest 2.4% increase to the end of the study period in April 2023 (95% CI [2.0,2.7]). CONCLUSIONS: A 45% reduction in oxycodone consumption in Australia from 2019 to 2020 coincided with national policy changes that aimed to reduce consumption of prescription opioids. The overall declining trend in consumption was suggestive of the effectiveness of national interventions in reducing pharmaceutical opioid use. Wastewater-based epidemiology provides an effective approach for assessing the effectiveness of controlled substances policy changes.

Swipe to Inhale: Tobacco-Related Content on Social Media and Susceptibility to Tobacco Use.

INTRODUCTION: Research has linked youth exposure and engagement with tobacco-related content on social media to behavioral changes; however, there is a lack of studies exploring the source and types of such content and their impact on youth's susceptibility to tobacco use. This study examined the association between the type and source of content posted on social media and susceptibility to tobacco use, defined as curiosity or intention to use tobacco or e-cigarettes. METHODS: Data were from the Population Assessment Tobacco and Health study, a nationally representative cohort study of U.S. youth (n=5,652). This analysis conducted in March 2024, focused on Wave 6 (2021), examining youth who used social media in the past month and did not use cigarettes or e-cigarettes. Multivariable logistic regression was performed to evaluate the associations. RESULTS: Of the youth who had used social media in the past month (88.7%), 61.4% had encountered tobacco-related content. Exposure to such content was associated with greater susceptibility to e-cigarette use (OR=1.49, 95% CI: 1.38-1.62) and cigarette use (OR=1.29, 95% CI: 1.17-1.43). Daily or near-daily exposure to tobacco-related content compared to non-exposed respondents was associated with greater odds of susceptibility to tobacco use (OR=1.53, 95% CI: 1.37-1.71). Only posts made by celebrities and influencers were associated with a greater susceptibility to tobacco use. CONCLUSIONS: Regular exposure to tobacco-related content on social media, particularly content shared by celebrities and social media influencers, was associated with susceptibility to tobacco use. These findings underscore the need for targeted interventions to mitigate the effects of social media influencers on youth.

The Gaming Disorder Identification Test (GADIT) - A screening tool for Gaming Disorder based on ICD-11.

Background: Gaming Disorder was included as an addictive disorder in the latest version of the International Classification of Diseases (ICD-11), published in 2022. The present study aimed to develop a screening tool for Gaming Disorder, the Gaming Disorder Identification Test (GADIT), based on the four ICD-11 diagnostic criteria: impaired control, increasing priority, continued gaming despite harm, and functional impairment. Method: We reviewed 297 questionnaire items from 48 existing gaming addiction scales and selected 68 items based on content validity. Two datasets were collected: 1) an online panel (N = 803) from Australia, United States, United Kingdom and Canada, split into a development set (N = 589) and a validation dataset (N = 214); and 2) a university sample (N = 408) from Australia. Item response theory and confirmatory factor analyses were conducted to select eight items to form the GADIT. Validity was established by regressing the GADIT against known correlates of Gaming Disorder. Results: Confirmatory factor analyses of the GADIT showed good model fit (RMSEA=<0.001-0.108; CFI = 0.98-1.00), and internal consistency was excellent (Cronbach's alphas = 0.77-0.92). GADIT scores were strongly associated with the Internet Gaming Disorder Test (IGDT-10), and significantly associated with gaming intensity, eye fatigue, hand pain, wrist pain, back or neck pain, and excessive in-game purchases, in both the validation and the university sample datasets. Conclusion: The GADIT has strong psychometric properties in two independent samples from four English-speaking countries collected through different channels, and shown validity against existing scales and variables that are associated with Gaming Disorder. A cut-off of 5 is tentatively recommended for screening for Gaming Disorder.

Targeting inflammasome complexes as a novel therapeutic strategy for mood disorders.

INTRODUCTION: Inflammasome complexes, especially NLRP3, have gained great attention as a potential therapeutic target in mood disorders. NLRP3 triggers a caspase 1-dependent release of the inflammatory cytokines IL-1ß and IL-18, and seems to interact with purinergic and kynurenine pathways, all of which are implicated in mood disorders development and progression. AREAS COVERED: Emerging evidence supports NLRP3 inflammasome as a promising pharmacological target for mood disorders. We discussed the available evidence from animal models and human studies and provided a reflection on drawbacks and perspectives for this novel target. EXPERT OPINION: Several studies have supported the involvement of NLRP3 inflammasome in MDD. However, most of the evidence comes from animal models. The role of NLRP3 inflammasome in BD as well as its anti-manic properties is not very clear and requires further exploration. There is evidence of anti-manic effects of P2×R7 antagonists associated with reduction in the brain levels of IL-1ß and TNF-α in a murine model of mania. The involvement of other NLRP3 inflammasome expressing cells besides microglia, like astrocytes, and of other inflammasome complexes in mood disorders also deserves further investigation. Preclinical and clinical characterization of NLRP3 and other inflammasomes in mood disorders is needed before considering translational approaches, including clinical trials.

The nature and characteristics of problem gaming, with a focus on ICD-11 diagnoses.

PURPOSE OF REVIEW: This review describes the diagnoses related to problem gaming that are included in ICD-11, published by the WHO in 2022. It summarizes the recent literature on the prevalence of Gaming Disorder, its structure, antecedents and comorbidities, and explores whether the range of diagnoses currently available adequately covers the range of experiences seen with problem gaming. RECENT FINDINGS: Overall, between 3 and 6% of the population worldwide are reported to have a gaming disorder as defined by ICD-11 or DSM-5. However, most studies are constrained by methodological issues such as nonrepresentative samples and the use of brief questionnaires to determine prevalence. ICD-11 Gaming Disorder is a psychometrically sound diagnosis. There is no diagnosis that currently captures the experience of harm from gaming, where the requirements for the diagnosis of Gaming Disorder are not reached. SUMMARY: There is evidence in support of the proposed new entity of 'Harmful Gaming', which encompasses mental and physical harm/impairment due to a repeated pattern of gaming, but where requirements for the diagnosis of Gaming Disorder are not met. Such a diagnosis would complete the spectrum of diagnoses available for problem or unhealthy gaming, similar to those for unhealthy substance use, and would provide a framework for a public health approach to reducing the overall harm from unhealthy gaming.

Alcohol use and alcohol use disorders in sub-Saharan Africa: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Population-level alcohol use data are available from high-income countries, but limited research has been conducted in sub-Saharan Africa. This systematic review and meta-analysis aimed to summarize population-level alcohol use in sub-Saharan Africa. METHOD: Databases searched included PubMed, EMBASE, PsycINFO and AJOL, without language restrictions. Searches were also conducted in the Global Health Data Exchange (GHDx) and Google Scholar. Search terms encompassed 'substance' or 'substance-related disorders' and 'prevalence' and 'sub-Saharan Africa'. We included general population studies on alcohol use (including any use, high-risk alcohol use and alcohol use disorders) from 2018 onwards. Prevalence data for alcohol use among sub-Saharan African adolescents (10-17) and adults (18+) were extracted. Analyses included life-time and past 12- and 6-month alcohol use. RESULTS: We included 141 papers. Among adolescents, the life-time prevalence of alcohol use was 23.3% [95% confidence interval (CI) = 11.3-37.1%], 36.2% (CI = 18.4-56.1%) in the past year and 11.3% (CI = 4.5-20.4%) in the past 6 months. Among adolescents, 12-month prevalence of alcohol use disorder and alcohol dependence were 7.7% (CI = 0.0-27.8%) and 4.1% (CI = 1.4-7.9%), respectively. Among adults, the life-time prevalence of alcohol use was 34.9% (CI = 17.7-54.1%), 27.1% (CI = 5.0-56.4%) in the past year and 32.2% (CI = 19.8-46.0%) in the past 6 months. Among adults, the 12-month prevalence of alcohol use disorder and alcohol dependence were 9.5% (CI = 0.0-30.4%) and 4.3% (CI = 0.8-9.8%), respectively. The highest weighted life-time prevalence of alcohol use, 86.4%, was reported in Tanzania among adults. The highest weighted past 6-month prevalence of alcohol use, 80.6%, was found in Zambia among adolescents. CONCLUSION: Alcohol use patterns vary across countries and subregions within sub-Saharan Africa, and comprehensive population-level data on alcohol use remain scarce in numerous sub-Saharan African countries. The prevalence of alcohol use disorder is common among adolescents in sub-Saharan Africa.

Quinolinic acid links kidney injury to brain toxicity.

Kidney dysfunction often leads to neurological impairment, yet the complex kidney-brain relationship remains elusive. We employed spatial and bulk metabolomics to investigate a mouse model of rapid kidney failure induced by mouse double minute 2 ( Mdm2) conditional deletion in the kidney tubules to interrogate kidney and brain metabolism. Pathway enrichment analysis of focused plasma metabolomics panel pinpointed tryptophan metabolism as the most altered pathway with kidney failure. Spatial metabolomics showed toxic tryptophan metabolites in the kidneys and brains, revealing a novel connection between advanced kidney disease and accelerated kynurenine degradation. In particular, the excitotoxic metabolite quinolinic acid was localized in ependymal cells adjacent to the ventricle in the setting of kidney failure. These findings were associated with brain inflammation and cell death. A separate mouse model of acute kidney injury also had an increase in circulating toxic tryptophan metabolites along with altered brain inflammation. Patients with advanced CKD similarly demonstrated elevated plasma kynurenine metabolites and quinolinic acid was uniquely correlated with fatigue and reduced quality of life in humans. Overall, our study identifies the kynurenine pathway as a bridge between kidney decline, systemic inflammation, and brain toxicity, offering potential avenues for diagnosis and treatment of neurological issues in kidney disease.

Effectiveness of cannabis use and cannabis use disorder interventions: a European and international data synthesis.

This data synthesis examined the effectiveness of behavioural and pharmacological approaches for cannabis treatment. We integrated findings from high level evidence studies and prioritised data from Europe when available. The synthesis found that only a relatively small number of published behavioural and pharmacological studies on cannabis interventions have been conducted in Europe. Applying both European and non-European data, it was found that Cognitive Behavioural Therapy (CBT) and/or Motivational Enhancement Therapy (MET) improved short-term outcomes in the frequency of cannabis use and dependency severity, although abstinence outcomes were less consistent. These improvements were typically not maintained nine months after treatment. CBT and MET (or combined CBT + MET) treatments that extend beyond four sessions were more effective than fewer sessions over a shorter duration. Combining CBT or MET (or combined CBT + MET) with adjunctive Contingency Management (CM) improved therapeutic outcomes. No pharmacotherapies have been approved for the management of cannabis use, cannabis use disorders or cannabis withdrawal. Despite only weak evidence to support the use of pharmacological agents, some are used 'off-label' to manage withdrawal symptoms outside clinical trials.

Personalized neoantigen vaccine and pembrolizumab in advanced hepatocellular carcinoma: a phase 1/2 trial.

Programmed cell death protein 1 (PD-1) inhibitors have modest efficacy as a monotherapy in hepatocellular carcinoma (HCC). A personalized therapeutic cancer vaccine (PTCV) may enhance responses to PD-1 inhibitors through the induction of tumor-specific immunity. We present results from a single-arm, open-label, phase 1/2 study of a DNA plasmid PTCV (GNOS-PV02) encoding up to 40 neoantigens coadministered with plasmid-encoded interleukin-12 plus pembrolizumab in patients with advanced HCC previously treated with a multityrosine kinase inhibitor. Safety and immunogenicity were assessed as primary endpoints, and treatment efficacy and feasibility were evaluated as secondary endpoints. The most common treatment-related adverse events were injection-site reactions, observed in 15 of 36 (41.6%) patients. No dose-limiting toxicities or treatment-related grade ≥3 events were observed. The objective response rate (modified intention-to-treat) per Response Evaluation Criteria in Solid Tumors 1.1 was 30.6% (11 of 36 patients), with 8.3% (3 of 36) of patients achieving a complete response. Clinical responses were associated with the number of neoantigens encoded in the vaccine. Neoantigen-specific T cell responses were confirmed in 19 of 22 (86.4%) evaluable patients by enzyme-linked immunosorbent spot assays. Multiparametric cellular profiling revealed active, proliferative and cytolytic vaccine-specific CD4+ and CD8+ effector T cells. T cell receptor ß-chain (TCRß) bulk sequencing results demonstrated vaccination-enriched T cell clone expansion and tumor infiltration. Single-cell analysis revealed posttreatment T cell clonal expansion of cytotoxic T cell phenotypes. TCR complementarity-determining region cloning of expanded T cell clones in the tumors following vaccination confirmed reactivity against vaccine-encoded neoantigens. Our results support the PTCV's mechanism of action based on the induction of antitumor T cells and show that a PTCV plus pembrolizumab has clinical activity in advanced HCC. ClinicalTrials.gov identifier: NCT04251117 .

Long-term benefits of hematopoietic stem cell-based macrophage/microglia delivery of GDNF to the CNS in a mouse model of Parkinson's disease.

Glial cell line-derived neurotrophic factor (GDNF) protects dopaminergic neurons in various models of Parkinson's disease (PD). Cell-based GDNF gene delivery mitigates neurodegeneration and improves both motor and non-motor functions in PD mice. As PD is a chronic condition, this study aims to investigate the long-lasting benefits of hematopoietic stem cell (HSC)-based macrophage/microglia-mediated CNS GDNF (MMC-GDNF) delivery in an MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) mouse model. The results indicate that GDNF treatment effectively ameliorated MPTP-induced motor deficits for up to 12 months, which coincided with the protection of nigral dopaminergic neurons and their striatal terminals. Also, the HSC-derived macrophages/microglia were recruited selectively to the neurodegenerative areas of the substantia nigra. The therapeutic benefits appear to involve two mechanisms: (1) macrophage/microglia release of GDNF-containing exosomes, which are transferred to target neurons, and (2) direct release of GDNF by macrophage/microglia, which diffuses to target neurons. Furthermore, the study found that plasma GDNF levels were significantly increased from baseline and remained stable over time, potentially serving as a convenient biomarker for future clinical trials. Notably, no weight loss, altered food intake, cerebellar pathology, or other adverse effects were observed. Overall, this study provides compelling evidence for the long-term therapeutic efficacy and safety of HSC-based MMC-GDNF delivery in the treatment of PD.

Training the Next Generation of Data Monitoring Committee Members: An Initiative of the Heart Failure Collaboratory.

Clinical trials are vital for assessing therapeutic interventions. The associated data monitoring committees (DMCs) safeguard patient interests and enhance trial integrity, thus promoting timely, reliable evaluations of those interventions. We face an urgent need to recruit and train new DMC members. The HFC (Heart Failure Collaboratory), a multidisciplinary public-private consortium of academics, trialists, patients, industry representatives, and government agencies, is working to improve the clinical trial ecosystem. The HFC aims to improve clinical trial efficiency and quality by standardizing concepts, and to help meet the demand for experienced individuals on DMCs by creating a standardized approach to training new members. This paper discusses the HFC's training workshop, and an apprenticeship model for new DMC members. It describes opportunities and challenges DMCs face, along with common myths and best practices learned through previous experiences, with an emphasis on data confidentiality and need for quality independent statistical reporting groups.

Designing observational studies for credible causal inference in addiction research-Directed acyclic graphs, modified disjunctive cause criterion and target trial emulation.

Randomized controlled trials (RCTs) are considered the gold standard for causal inference. With a sufficient sample size, randomization removes confounding up to the time of randomization and allows the treatment effect to be isolated. However, RCTs may have limited generalizability and transportability and are often not feasible in addiction research due to ethical or logistical constraints. The importance of observational studies from real-world settings has been increasingly recognized in research on health. This paper provides an overview of modern approaches to designing observational studies that enable causal inference. It illustrates three key techniques, Directed Acyclic Graphs (DAGs), modified Disjunctive Cause Criterion and Target Trial Emulation, and discusses the strengths and limitations of their applications.

Participation in Australian drug treatment programs for individuals engaging in high-risk substance use: Data from a nationally representative sample.

INTRODUCTION: Substance use, including drugs, alcohol and smoking have a significant health, social and economic impact. We aim to assess the rate and factors associated with treatment access among individuals with high-risk substance use. METHOD: This study is a cross-sectional analysis of the 2019 Australian National Drug Strategy Household Survey (N = 22,015). Participants were persons with high-risk substance use based on the Alcohol, Smoking and Substance Involvement Screening Test-Lite (ASSIST-Lite) and current smokers. We measured self-reports of past 12-month engagement in a tobacco, alcohol or other drugs treatment program. RESULTS: Overall, 0.4% had high-risk drug use (0.3% cannabis, 0.1% meth/amphetamine or 0.1% opioids), 7.4% had high-risk alcohol use, and 14.0% currently smoked. Among high-risk users, past 12-month treatment access rates were 50.6% [22.3-78.9%] for opioids, 27.1% [8.1-46.1%] for meth/amphetamine, 14.5% [4.3-24.7%] for cannabis, 9.6% [8.1-11.0%] for alcohol and 11.7% [10.6-12.9%] for current smoking. The primary source of treatment support was information and education (12.7% drugs, 4.6% alcohol, 4.0% smoking), followed by counselling (6.7% drugs, 4.5% alcohol, 3.0% smoking). Online or internet support was accessed by 5.9% (drug) and 1.6% (alcohol) people with high-risk use. Psychological distress was associated with treatment access (drugs: odds ratio 3.03 [0.77-11.95], p = 0.111; alcohol: odds ratio 3.16 [2.20-4.56], p ≤ 0.001; smoking: odds ratio 1.95 [1.52-2.49], p ≤ 0.001). DISCUSSION AND CONCLUSIONS: The proportion of people engaging in risky substance use who had used treatment programs remains low, especially for alcohol. Public health strategies to scale up treatment access are warranted.

A systematic review and meta-analysis of the relationship between youth drinking, self-posting of alcohol use and other social media engagement (2012-21).

BACKGROUND AND AIM: Social networking sites (SNS) are interactive internet-based social platforms that facilitate information sharing. A growing body of literature on exposure to, and self-posting of, alcohol-related content on SNS has examined the relationship between SNS use and alcohol consumption in young people. This study aims to synthesise the literature exploring the relationship between exposure (i.e. viewing or listening of alcohol-related media) and self-posting (i.e. uploading images or text of alcohol content) of alcohol-related media on SNS on alcohol consumption. METHODS: A pre-registered systematic review was conducted in June 2022 within PubMed, Scopus, PsycINFO and Web of Science. Original prospective and cross-sectional studies assessing youth and young adults (≤ 24 years of age) that measured exposure to alcohol-related media or posting of alcohol-related content on SNS and self-reported alcohol consumption outcomes were included. Meta-analyses were conducted on comparable methodologies. RESULTS: Thirty studies were included (n = 19,386). Meta-analyses of cross-sectional studies showed both greater exposure (five studies; pooled ß = 0.34, 95% confidence interval [CI] = 0.23, 0.44, i2 = 27.7%) and self-posting of alcohol-related content (six studies; pooled ß = 0.57, 95%CI = 0.25,0.88, i2 = 97.8%) was associated with greater alcohol consumption. Meta-analyses of three prospective studies also identified that greater exposure predicted greater future alcohol consumption (three studies; pooled ß = 0.13, 95%CI = 0.11,0.15, i2 = 0.0%). Narrative analyses of studies that could not be meta-analysed due to incompatible methodologies were also conducted. Most studies (all four prospective, one of two cross-sectional) identified positive associations between exposure to alcohol-related content and greater average consumption. Most studies (three of four prospective, four of six cross-sectional) reported a positive association between of alcohol-related self-posting and greater average alcohol consumption. CONCLUSIONS: Both exposure to, and self-posting of, alcohol-related content on social networking sites are positively associated with current average consumption, problem drinking, and drinking frequency.

The contribution of pain catastrophizing, depression and anxiety symptoms among patients with persistent pain and opioid misuse behaviours.

BACKGROUND: Anxiety, depression and pain catastrophizing are independently associated with risk of opioid misuse in patients with persistent pain but their relationship to current opioid misuse, when considered together, is poorly understood. This study will assess the relative contribution of these modifiable, and distinct psychological constructs to current opioid misuse in patients with persistent pain. METHODS: One hundred and twenty-seven patients referred to a specialized opioid management clinic for prescription opioid misuse within a tertiary pain service were recruited for this study. The Pain Catastrophizing Scale, Depression, Anxiety and Stress Scales and the Current Opioid Misuse Measure were administered pre-treatment. Pain severity and morphine equivalent dose based on independent registry data were also recorded. RESULTS: Higher levels of pain catastrophizing, depression, and anxiety were significantly associated with higher current opioid misuse (r = .475, 0.599, and 0.516 respectively, p < .01). Pain severity was significantly associated with pain catastrophizing (r = .301, p < .01). Catastrophizing, depression, and anxiety explained an additional 11.56% of the variance (R2 change = 0.34, p < .01) over and above age, gender, pain severity and morphine equivalent dose. Depression was the only significant variable at Step 2 (ß = 0.62, p < .01). CONCLUSION: Findings show that in a sample of people with persistent pain referred for treatment for opioid misuse, depression contributes over and above that of anxiety and pain catastrophizing. Theoretical and clinical practice implications are presented.

What is the hype on #MedicinalCannabis in the United States? A content analysis of medicinal cannabis tweets.

INTRODUCTION: Medicinal cannabis is now legal in 44 US jurisdictions. Between 2020 and 2021 alone, four US jurisdictions legalised medicinal cannabis. The aim of this study is to identify themes in medicinal cannabis tweets from US jurisdictions with different legal statuses of cannabis from January to June 2021. METHODS: A total of 25,099 historical tweets from 51 US jurisdictions were collected using Python. Content analysis was performed on a random sample of tweets accounting for the population size of each US jurisdictions (n = 750). Results were presented separately by tweets posted from jurisdictions where all cannabis use (non-medicinal and medicinal) is 'fully legalised', 'illegal' and legal for 'medical-only' use. RESULTS: Four themes were identified: 'Policy', 'Therapeutic value', 'Sales and industry opportunities' and 'Adverse effects'. Most of the tweets were posted by the public. The most common theme was related to 'Policy' (32.5%-61.5% of the tweets). Tweets on 'Therapeutic value' were prevalent in all jurisdictions and accounted for 23.8%-32.1% of the tweets. Sales and promotional activities were prominent even in illegal jurisdictions (12.1%-26.5% of the tweets). Fewer than 10% of tweets were about intoxication and withdrawal symptoms. DISCUSSION AND CONCLUSION: This study has explored if content themes of medicinal cannabis tweets differed by cannabis legal status. Most tweets were pro-cannabis and they were related to policy, therapeutic value, and sales and industry opportunities. Tweets on unsubstantiated health claims, adverse effects and crime warrants continued surveillance as these conversations could allow us to estimate cannabis-related harms to inform health surveillance.

Churn in Supplemental Nutrition Assistance Program: Changes in Medicaid Expenditure and Acute Care Utilization.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) provides financial assistance to low-income individuals and families to help them purchase food. However, when participants experience short-term disenrollment from the program, known as churn, it can disrupt their health care usage patterns or result in acute health care needs due to the loss of financial benefits and time burden required to reapply for SNAP. OBJECTIVE: The objective of this study was to examine the changes in health care expenditures and acute care utilization during periods of SNAP churn compared with nonchurn periods among those who churn during the study period. RESEARCH DESIGN: Longitudinal analysis of Pennsylvania Medicaid claims data for enrollees participating in SNAP between 2016 and 2018 using individual fixed-effects models. We add to the literature by estimating whether these changes varied based on the amount of SNAP benefit lost, or differed between adults and children. RESULTS: We found that SNAP churn was associated with reductions in pharmacy and primary care spending across all SNAP benefit levels and age groups. Specifically, our findings indicate a reduction of 4%-6% in pharmacy expenditures for adults and 2%-4% for children. Moreover, there was a 3%-4% decrease in primary care expenditures for adults and a 4%-6% decrease for children. Acute care utilization did not significantly change during a SNAP churn period. CONCLUSION: Our findings of decreases in pharmacy and primary care spending suggest that preventing SNAP churn may help reduce instances where adult and child participants forgo necessary care.

The Influence of Branched-Chain Amino Acid Supplementation on Fatigue and Tryptophan Metabolism After Acute and Chronic Exercise in Older Adults: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: Fatigue is a strong predictor of negative health outcomes in older adults. Kynurenine, a metabolite of tryptophan, is strongly associated with fatigue. Reductions in fatigue are observed with exercise; however, exercise training does not completely alleviate symptoms. Branched-chain amino acids (BCAAs) have been shown to have advantageous effects on exercise performance and compete with kynurenine for transport into the central nervous system. Thus, the combination of BCAA and exercise may exert synergized effects of mental and physical fatigue. Therefore, we hypothesize that BCAA added to exercise will shift kynurenine metabolism toward enhanced synthesis of kynurenic acid, thereby reducing fatigue. OBJECTIVE: This randomized, double-blind, placebo-controlled trial aims to compare the effects of acute (approximately 45 min) and chronic (8 wk) exercise with and without BCAA supplementation on mental and physical fatigue and assess whether the hypothesized outcomes are modulated by changes in kynurenine metabolism in 30 older adults (n=15, 50% per group). METHODS: Older adults (aged 60-80 y) who do not exercise >2 days per week and self-report fatigue (≥3 on a scale of 1-10) will be recruited. Participants will be randomized to either the exercise+BCAA group or exercise+placebo group. Participants will engage in high-volume, moderate-intensity, whole-body exercise training (aerobic and resistance exercise; either in-person or web-based sessions) 3 times per week for 8 weeks. In addition, participants will consume daily either 100 mg/kg body weight of BCAA (2:1:1 leucine:isoleucine:valine) or placebo (maltodextrin) throughout the 8-week intervention. BCAA and placebo powders will be identical in color and dissolved in 400 mL of water and 2.5 g of a calorie-free water flavor enhancer. Muscle biopsies will be collected before and after the intervention after a 12-hour fast to examine changes in the biomarkers of tryptophan metabolism and inflammation. Our primary outcomes include changes in mental and physical fatigue and metabolism after the 8-week exercise training between the 2 groups. Mental and physical fatigue will be measured before and after the intervention. Mental fatigue will be subjectively assessed through the completion of validated questionnaires. Physical fatigue will be measured by isometric handgrip, 1-repetition maximum, chair rise, 400-meter walk, and cardiopulmonary exercise tests. RESULTS: The study was funded in March 2022, with an anticipated projected data collection period lasting from January 2023 through December 2023. CONCLUSIONS: The discovery that kynurenine concentrations are associated with fatigue and are responsive to BCAA supplementation during exercise training could have important implications for the development of future interventions, both lifestyle and pharmacologic, to treat fatigue in older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT05484661; https://www.clinicaltrials.gov/study/NCT05484661. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52199.

Viral Vaping: A systematic review and meta analysis of e-cigarette and Tobacco-Related social media content and its influence on youth behaviours and attitudes.

AIMS: E-cigarette and tobacco-related content on social media continues to rise from lax restrictions on both personal and promotional posts. This content has been linked to various mechanisms of increased e-cigarette and tobacco use (i.e., lower risk perceptions and increased susceptibility). This study aimed to synthesis the association between exposure to e-cigarette and tobacco-related content and youth behaviours and attitudes. METHODS: A comprehensive search was conducted on PubMed, Scopus, PsycINFO and Web of Science. Studies published post-2004 reporting effect estimates for exposure or engagement with e-cigarette or tobacco content on social media and behaviour or attitude outcomes were included. RESULTS: Thirty-two studies (N = 274,283, aged 9 to 25 years) were included for synthesis. Meta-analyses revealed significant associations between engagement with tobacco content and use (OR 2.21; 95% CI = 1.27-3.82, p =.005; I2 = 96.4%), exposure to tobacco content and never users' lower risk perceptions (OR 0.68; 95% CI = 0.49-0.91; p =.011; I2 = 78.2%), and exposure to e-cigarette content and use (OR 1.37; 95% CI = 0.99-1.88; p = 0.058; I2 = 64.4%). There was no observed relationship between exposure to tobacco content and ever users' risk perceptions (OR 0.83; 95% CI = 0.61-1.13; p =.231; I2 = 83.5%). Qualitative synthesis found significant associations between tobacco exposure and increased current use and pro-tobacco attitudes; e-cigarette exposure and increased susceptibility and lower risk perceptions; tobacco engagement and increased susceptibility; e-cigarette engagement and increased use; dual exposure and increased susceptibility; and dual engagement and increased dual use. Mixed findings were identified for the influence of e-cigarette exposure on attitudes, tobacco exposure on susceptibility, dual exposure on dual use behaviours, and dual engagement on dual susceptibility. CONCLUSIONS: Findings suggest an association between exposure and engagement to e-cigarette or tobacco products on social media and use or pro-use attitudes among youth. Further substantive research in the area of youth-specific use and attitudes following exposure and engagement with e-cigarette and tobacco content is needed to quantify this association.