The impact of minimum unit pricing on traumatic brain injury in Scotland: a retrospective cohort study of routine national data.

BACKGROUND: Traumatic brain injury (TBI) is a common cause of disability and mortality and is associated with alcohol consumption. On 1st May 2018, the Scottish Government introduced Minimum Unit Pricing (MUP) legislation which set the floor price at which alcohol can be sold to 50 pence per unit. While MUP has led to a 7.6% decrease in off trade alcohol purchases, there are limited studies investigating the clinical impact of this legislation. This study aims to explore the impact of MUP on traumatic brain injury in Scotland. METHODS: Retrospective cohort study using routinely collected national data collated by the Scottish Trauma Audit Group. Data were requested for all TBI incidents from 1st May to 31st December for both 2017 and 2018. Primary outcome was alcohol-related TBI. Secondary outcomes were injury mechanism, injury severity, clinical course, and short-term mortality. Analysis was conducted using multiple regression models adjusted for age, sex, season, and deprivation. RESULTS: A total of 1166 patients (66% male, and 46% in the 60-79-year bracket) were identified. Alcohol-related TBI was evident in 184 of 509 (36%) patients before MUP and in 239 of 657 (36%) patients injured after its implementation (p = 0.638). Further, there was no change in injury mechanism, injury severity, hospital course and short-term mortality of TBI after MUP. CONCLUSIONS: MUP has not resulted in a change in alcohol-related TBI nor in the mechanism and severity of TBI. Limitations in two-point analysis mean that findings should be interpreted with caution and further studies investigating the clinical outcomes of MUP must be conducted.

Physiotherapy breathing retraining for asthma: a randomised controlled trial.

BACKGROUND: Despite effective pharmacotherapy, asthma continues to impair quality of life for most patients. Non-pharmacological approaches, including breathing retraining, are therefore of great interest to patients. However, clinicians rarely advocate breathing retraining and access to this intervention is restricted for most patients due to the limited availability of suitable physiotherapists and poor integration of breathing retraining into standard care. We aimed to assess the effectiveness of a digital self-guided breathing retraining intervention. METHODS: In this randomised controlled trial, we recruited patients from 34 general practices in the UK. Eligibility criteria for patients with asthma were broad, comprising a physician diagnosis of asthma, age of 16-70 years, receipt of at least one anti-asthma medication in the previous year, and impaired asthma-related quality of life (Asthma Quality of Life Questionnaire [AQLQ] score of <5·5). We developed a self-guided intervention, which was delivered as a DVD plus a printed booklet (DVDB). Participants were randomly assigned to receive either the DVDB intervention, three face-to-face breathing retraining sessions, or standard care, in a 2:1:2 ratio, for 12 months. Randomisation was achieved using the Southampton Clinical Trials Unit telephone randomisation service by use of random number generators. The primary outcome was the AQLQ score in the intention-to-treat population at 12 months. The trial was powered to show equivalence between the two active intervention groups, and superiority of both intervention groups over usual care. Secondary outcomes included patient-reported and physiological measures of asthma control, patient acceptability, and health-care costs. This trial was registered with International Standard Randomised Controlled Trial Number registry, number ISRCTN88318003. FINDINGS: Between Nov 5, 2012 and Jan 28, 2014, invitations to participate in the study were sent to 15 203 patients with general practitioner-diagnosed asthma, of whom 655 were recruited into the study. AQLQ scores at 12 months were significantly higher in the DVDB group (mean 5·40, SD 1·14) than in the usual care group (5·12, SD 1·17; adjusted mean difference 0·28, 95% CI 0·11 to 0·44), and in the face-to-face group (5·33, SD 1·06) than in the usual care group (adjusted mean difference 0·24, 95% CI 0·04 to 0·44); AQLQ scores were similar between the DVDB group and the face-to-face group (0·04, 95% CI -0·16 to 0·24). There were no significant differences between the randomisation groups in FEV1 or fraction of exhaled nitric oxide. 744 adverse events occurred in 272 patients: 101 (39%) of 261 patients in the DVDB group, 55 (42%) of 132 patients in the face-to-face group, and 132 (50%) of 262 in the usual care group, with patients reporting one or more event. 11 (4%) patients in the DVDB group, four (3%) patients in the face-to-face group, and 20 (8%) patients in the usual care group had a serious adverse event. INTERPRETATION: Breathing retraining programmes improve quality of life in patients with incompletely controlled asthma despite having little effect on lung function or airway inflammation. Such programmes can be delivered conveniently and cost-effectively as a self-guided digital audiovisual programme, so might also reduce health-care costs. FUNDING: UK National Institute of Health Research.

A randomised controlled study of the effectiveness of breathing retraining exercises taught by a physiotherapist either by instructional DVD or in face-to-face sessions in the management of asthma in adults.

BACKGROUND: Asthma control is suboptimal, resulting in quality of life (QoL) impairment and costs. Breathing retraining exercises have evidence of effectiveness as adjuvant treatment, but are infrequently used. OBJECTIVES: To transfer the contents of a brief (three-session) physiotherapist-delivered breathing retraining programme to a digital versatile disc (DVD) and booklet format; to compare the effectiveness of the self-guided intervention with that of 'face-to-face' physiotherapy and usual care for QoL and other asthma-related outcomes; to perform a health economic assessment of both interventions; and to perform a process evaluation using quantitative and qualitative methods. DESIGN: Parallel-group three-arm randomised controlled trial. SETTING: General practice surgeries in the UK. PARTICIPANTS: In total, 655 adults currently receiving asthma treatment with impaired asthma-related QoL were randomly allocated to the DVD (n = 261), physiotherapist (n = 132) and control (usual care) (n = 262) arms in a 2 : 1 : 2 ratio. It was not possible to blind participants but data collection and analysis were performed blinded. INTERVENTIONS: Physiotherapy-based breathing retraining delivered through three 'face-to-face' respiratory physiotherapist sessions or a self-guided programme (DVD plus our theory-based behaviour change booklet) developed by the research team, with a control of usual care. MAIN OUTCOME MEASURES: The primary outcome measure was asthma-specific QoL, measured using the Asthma Quality of Life Questionnaire (AQLQ). Secondary outcomes included asthma symptom control [Asthma Control Questionnaire (ACQ)], psychological state [Hospital Anxiety and Depression Scale (HADS)], hyperventilation symptoms (Nijmegen questionnaire), generic QoL [EuroQol-5 Dimensions (EQ-5D)], assessments of airway physiology (spirometry) and inflammation (exhaled nitric oxide) and health resource use and costs. Assessments were carried out at baseline and at 3, 6 and 12 months post randomisation. Patient engagement and experience were also assessed using quantitative and qualitative methods. RESULTS: Primary efficacy analysis was between-group comparison of changes in AQLQ scores from baseline to 12 months in the intention-to-treat population with adjustments for prespecified covariates. Significant improvements occurred in the DVD group compared with the control group [adjusted mean difference 0.28, 95% confidence interval (CI) 0.11 to 0.44; p < 0.001] and in the face-to-face physiotherapy group compared with the control group (adjusted mean difference 0.24, 95% CI 0.04 to 0.44; p < 0.05), with equivalence between the DVD and the face-to-face physiotherapy groups (adjusted mean difference 0.04, 95% CI -0.16 to 0.24). In all sensitivity analyses, both interventions remained significantly superior to the control and equivalence between the interventions was maintained. In other questionnaire outcome measures and in the physiological measures assessed, there were no significant between-group differences. Process evaluations showed that participants engaged well with both of the active interventions, but that some participants in the DVD arm would have liked to receive tuition from a professional. Asthma health-care costs were lower in both intervention arms than in the control group, indicating 'dominance' for both of the interventions compared with the control, with lowest costs in the DVD arm. The rate of adverse events was lower in the DVD and face-to-face physiotherapy groups than in the control group. CONCLUSIONS: Only 10% of the potentially eligible population responded to the study invitation. However, breathing retraining exercises improved QoL and reduced health-care costs in adults with asthma whose condition remains uncontrolled despite standard pharmacological therapy, were engaged with well by patients and can be delivered effectively as a self-guided intervention. The intervention should now be transferred to an internet-based platform and implementation studies performed. Interventions for younger patients should be developed and trialled. TRIAL REGISTRATION: Current Controlled Trials ISRCTN88318003. FUNDING: This project was primarily funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 53. See the NIHR Journals Library website for further project information. Additional financial support was received from Comprehensive Local Research Networks.

Community pharmacy services for people with drug problems over two decades in Scotland: Implications for future development.

BACKGROUND: In Scotland community pharmacies are heavily involved in service delivery for people with drug problems (PWDP) as documented through surveys of all community pharmacies in 1995, 2000 and 2006. A further survey in 2014 enabled trends in service demand/provision to be analysed and provides insight into future development. METHODS: The lead pharmacist in every Scottish pharmacy (n=1246) was invited to complete a postal questionnaire covering attitudes towards PWDP and service provision and level of involvement in services (needle exchange, dispensing for PWDP and methadone supervision). Additional questions covered new services of take-home naloxone (THN) and pharmacist prescribing for opioid dependence. Telephone follow-up of non-responders covered key variables. A comparative analysis of four cross-sectional population surveys of the community pharmacy workforce (1995, 2000, 2006 and 2014) was undertaken. RESULTS: Completed questionnaires were returned by 709 (57%) pharmacists in 2014. Key variables (questionnaire or telephone follow-up) were available from 873 (70%). The proportion of pharmacies providing needle exchange significantly increased from 1995 to 2014 (8.6%, 9.5%, 12.2%, 17.8%, p<0.001) as did the proportion of pharmacies dispensing for the treatment of drug misuse (58.9%, 73.4%, 82.6% and 88%, p<0.001). Methadone was dispensed to 16,406 individuals and buprenorphine to 1777 individuals (increased from 12,400 and 192 respectively in 2006). Attitudes improved significantly from 1995 to 2014 (p<0.001). Being male and past training in drug misuse significantly predicted higher attitude scores (p<0.05) in all four years. Attitude score was a consistently significant predictor in all four years for dispensing for the treatment of drug misuse [OR=1.1 (1995 and 2006, CI 1.1-1.3, and 2014 CI 1.1-1.4) and 1.2 (2000), CI 1.3-1.5] and providing needle exchange [OR=1.1 (1995 and 2006), CI 1.1-1.2, 1.1-1.3 and 1.2 (2000 and 2014), CI 1.1-1.3 and 1.1-1.5]. In 2014, 53% of pharmacists felt part of the addiction team and 27.7% did not feel their role was valued by them. Nine pharmacists prescribed for opioid dependence. CONCLUSION: It is possible for pharmacy workforce attitudes and service engagement to improve over time. Training was key to these positive trends. Communication with the wider addiction team could be further developed.