Youth drinking in decline: What are the implications for public health, public policy and public debate?

Youth drinking has declined across most high-income countries in the last 20 years. Although researchers and commentators have explored the nature and drivers of decline, they have paid less attention to its implications. This matters because of the potential impact on contemporary and future public health, as well as on alcohol policy-making. This commentary therefore considers how youth drinking trends may develop in future, what this would mean for public health, and what it might mean for alcohol policy and debate. We argue that the decline in youth drinking is well-established and unlikely to reverse, despite smaller declines and stabilising trends in recent years. Young people also appear to be carrying their lighter drinking into adulthood in at least some countries. This suggests we should expect large short- and long-term public health benefits. The latter may however be obscured in population-level data by increased harm arising from earlier, heavier drinking generations moving through the highest risk points in the life course. The likely impact of the decline in youth drinking on public and policy debate is less clear. We explore the possibilities using two model scenarios, the reinforcement and withdrawal models. In the reinforcement model, a 'virtuous' circle of falling alcohol consumption, increasing public support for alcohol control policies and apparent policy successes facilitates progressive strengthening of policy, akin to that seen in the tobacco experience. In the withdrawal model, policy-makers turn their attention to other problems, public health advocates struggle to justify proposed interventions and existing policies erode over time as industry actors reassert and strengthen their partnerships with government around alcohol policy. We argue that disconnects between the tobacco experience and the reinforcement model make the withdrawal model a more plausible scenario. We conclude by suggesting some tentative ways forward for public health actors working in this space.

The impact of disinvestment on alcohol and drug treatment delivery and outcomes: a systematic review.

BACKGROUND: In the context of substantial financial disinvestment from alcohol and drug treatment services in England, our aim was to review the existing evidence of how such disinvestments have impacted service delivery, uptake, outcomes and broader health and social implications. METHODS: We conducted a systematic review of quantitative and qualitative evidence (PROSPERO CRD42020187295), searching bibliographic databases and grey literature. Given that an initial scoping search highlighted a scarcity of evidence specific to substance use treatment, evidence of disinvestment from publicly funded sexual health and smoking cessation services was also included. Data on disinvestment, political contexts and impacts were extracted, analysed, and synthesized thematically. RESULTS: We found 20 eligible papers varying in design and quality including 10 related to alcohol and drugs services, and 10 to broader public health services. The literature provides evidence of sustained disinvestment from alcohol and drug treatment in several countries and a concurrent decline in the quantity and quality of treatment provision, but there was a lack of methodologically rigorous studies investigating the impact of disinvestment. CONCLUSIONS: This review identified a paucity of scientific evidence quantifying the impacts of disinvestment on alcohol and drug treatment service delivery and outcomes. As the global economy faces new challenges, a stronger evidence base would enable informed policy decisions that consider the likely public health impacts of continued disinvestment.

Effects of minimum unit pricing for alcohol in South Africa across different drinker groups and wealth quintiles: a modelling study.

OBJECTIVES: To quantify the potential impact of minimum unit pricing (MUP) for alcohol on alcohol consumption, spending and health in South Africa. We provide these estimates disaggregated by different drinker groups and wealth quintiles. DESIGN: We developed an epidemiological policy appraisal model to estimate the effects of MUP across sex, drinker groups (moderate, occasional binge, heavy) and wealth quintiles. Stakeholder interviews and workshops informed model development and ensured policy relevance. SETTING: South African drinking population aged 15+. PARTICIPANTS: The population (aged 15+) of South Africa in 2018 stratified by drinking group and wealth quintiles, with a model time horizon of 20 years. MAIN OUTCOME MEASURES: Change in standard drinks (SDs) (12 g of ethanol) consumed, weekly spend on alcohol, annual number of cases and deaths for five alcohol-related health conditions (HIV, intentional injury, road injury, liver cirrhosis and breast cancer), reported by drinker groups and wealth quintile. RESULTS: We estimate an MUP of R10 per SD would lead to an immediate reduction in consumption of 4.40% (-0.93 SD/week) and an increase in spend of 18.09%. The absolute reduction is greatest for heavy drinkers (-1.48 SD/week), followed by occasional binge drinkers (-0.41 SD/week) and moderate drinkers (-0.40 SD/week). Over 20 years, we estimate 20 585 fewer deaths and 9 00 332 cases averted across the five health-modelled harms.Poorer drinkers would see greater impacts from the policy (consumption: -7.75% in the poorest quintile, -3.19% in richest quintile). Among the heavy drinkers, 85% of the cases averted and 86% of the lives saved accrue to the bottom three wealth quintiles. CONCLUSIONS: We estimate that MUP would reduce alcohol consumption in South Africa, improving health outcomes while raising retail and tax revenue. Consumption and harm reductions would be greater in poorer groups.

Spring-mediated cranioplasty versus endoscopic strip craniectomy for sagittal craniosynostosis.

OBJECTIVE: Endoscopic strip craniectomy (ESC) and spring-mediated cranioplasty (SMC) are two minimally invasive techniques for treating sagittal craniosynostosis in early infancy. Data comparing the perioperative outcomes of these two techniques are sparse. Here, the authors hypothesized that outcomes would be similar between patients undergoing SMC and those undergoing ESC and conducted a study using the multicenter Pediatric Craniofacial Surgery Perioperative Registry (PCSPR). METHODS: The PCSPR was queried for infants under the age of 6 months who had undergone SMC or ESC for sagittal synostosis. SMC patients were propensity score matched 1:2 with ESC patients on age and weight. Primary outcomes were transfusion-free hospital course, intensive care unit (ICU) admission, ICU length of stay (LOS), and hospital length of stay (HLOS). The authors also obtained data points regarding spring removal. Comparisons of outcomes between matched groups were performed with multivariable regression models. RESULTS: The query returned data from 676 infants who had undergone procedures from June 2012 through September 2019, comprising 580 ESC infants from 32 centers and 96 SMC infants from 5 centers. Ninety-six SMC patients were matched to 192 ESC patients. There was no difference in transfusion-free hospital course between the two groups (adjusted odds ratio [aOR] 0.78, 95% CI 0.45-1.35). SMC patients were more likely to be admitted to the ICU (aOR 7.50, 95% CI 3.75-14.99) and had longer ICU LOSs (incident rate ratio [IRR] 1.42, 95% CI 1.37-1.48) and HLOSs (IRR 1.28, 95% CI 1.17-1.39). CONCLUSIONS: In this multicenter study of ESC and SMC, the authors found similar transfusion-free hospital courses; however, SMC infants had longer ICU LOSs and HLOSs. A trial comparing longer-term outcomes in SMC versus ESC would further define the roles of these two approaches in the management of sagittal craniosynostosis.

Clustering of health-related behaviours within children aged 11-16: a systematic review.

OBJECTIVE: We aimed to systematically review and synthesise evidence on the clustering of a broad range of health-related behaviours amongst 11-16 year olds. METHOD: A literature search was conducted in September 2019. Studies were included if they used cluster analysis, latent class analysis, prevalence odds ratios, principal component analysis or factor analysis, and considered at least three health-related behaviours of interest among 11-16 year olds in high-income countries. Health-related behaviours of interest were substance use (alcohol, cigarettes and other drug use) and other behavioural risk indicators (diet, physical activity, gambling and sexual activity). RESULTS: The review identified 41 studies, which reported 198 clusters of health-related behaviours of interest. The behaviours of interest reported within clusters were used to define eight behavioural archetypes. Some included studies only explored substance use, while others considered substance use and/or other health-related behaviours. Consequently, three archetypes were comprised by clusters reporting substance use behaviours alone. The archetypes were: (1) Poly-Substance Users, (2) Single Substance Users, (3) Substance Abstainers, (4) Substance Users with No/Low Behavioural Risk Indicators, (5) Substance Abstainers with Behavioural Risk Indicators, (6) Complex Configurations, (7) Overall Unhealthy and (8) Overall Healthy. CONCLUSION: Studies of youth health behavioural clustering typically find both a 'healthy' cluster and an 'unhealthy' cluster. Unhealthy clusters are often characterised by poly-substance use. Our approach to synthesising cluster analyses may offer a means of navigating the heterogeneity of method, measures and behaviours of interest in this literature.

Trends in the psychosocial characteristics of 11-15-year-olds who still drink, smoke, take drugs and engage in poly-substance use in England.

INTRODUCTION AND AIMS: Youth substance use is declining in many high-income countries. As adolescent substance use becomes less common, it may concentrate in higher-risk groups. This paper aims to examine how the psychosocial characteristics of young substance users in England have changed over time. DESIGN AND METHODS: Annual cross-sectional data from the 2001-2014 Smoking, Drinking and Drug Use Among Young People in England survey are analysed (n = 112 792, age: 11-15). Logistic and Poisson regression analyses are used to test whether the sex, socioeconomic status (SES) and prevalence of truancy and exclusion from school of those who drink alcohol, smoke cigarettes, take cannabis, take other drugs and engage in poly-substance use changed across the study period. RESULTS: Use of all substances decreased and there were shifts in the psychosocial characteristics of young smokers, illicit drug users and poly-substance users. The proportion of current smokers and ever-users of cannabis of low SES and who had been excluded increased significantly between 2001/2003-2014. The proportion of last month drug users who had been excluded from school also increased significantly and there were increases in the proportion of polysubstance-users who had truanted and been excluded. The proportion of low SES alcohol users who had been excluded also increased significantly, but this change was very small. There was no evidence of substance use becoming more or less concentrated in one gender. DISCUSSION AND CONCLUSIONS: There is some evidence that smoking, illicit drug use and poly-substance use are becoming more concentrated in potentially at risk populations. There is limited evidence of concentration amongst young drinkers.

Minimally Invasive Endoscopic Surgery for Infantile Craniosynostosis: A Longitudinal Cohort Study.

OBJECTIVE: To evaluate patient outcomes of minimally invasive endoscopic strip craniectomy (ESC) for craniosynostosis. STUDY DESIGN: This is a retrospective cohort analysis (2004-2018) of 500 consecutive infants with craniosynostosis treated by ESC with orthotic therapy at a single center. Operative outcomes included transfusions, complications, and reoperations as well as head circumference change based on World Health Organization percentiles. Multivariable logistic regression was used to identify risk factors associated with blood transfusion. Paired t tests were used for within-patient comparisons and Fisher exact test to compare syndromic and nonsyndromic subgroups. RESULTS: ESC was associated with low rates of blood transfusion (6.6%), complications (1.4%), and reoperations (3.0%). Risk factors for transfusion included syndromic craniosynostosis (P = .01) and multiple fused sutures (P = .02). Median surgical time was 47 minutes, and hospital length of stay 1 day. Transfusion and reoperation rates were higher among syndromic patients (both P < .001). Head circumference normalized by 12 months of age relative to World Health Organization criteria in infants with sagittal, coronal, and multisuture craniosynostosis (all P < .001). CONCLUSIONS: ESC is a safe, effective, and durable correction of infantile craniosynostosis. ESC can achieve head growth normalization with low risks of blood transfusion, complications, or reoperation. Early identification of craniosynostosis in the newborn period and prompt referral by pediatricians allows families the option of ESC vs larger and riskier open reconstruction procedures.

The decline in youth drinking in England-is everyone drinking less? A quantile regression analysis.

BACKGROUND AND AIMS: Youth alcohol consumption has declined significantly during the past 15 years in many high-income countries, which may have significant public health benefits. However, if the reductions in drinking occur mainly among lighter drinkers who are at lower risk, then rates of alcohol-related harm among young people today and adults in future may not fall in line with consumption. There is conflicting evidence from Swedish school studies, with some suggesting that all young people are drinking less, while others suggest that alcohol consumption among heavier drinkers may be stable or rising while average consumption declines. This paper extends the geographical focus of previous research and examines whether the decline in youth drinking is consistent across the consumption distribution in England. DESIGN: Quantile regression of 15 waves of repeat cross-sectional survey data. SETTING: England, 2001-16. PARTICIPANTS: A total of 31 882 schoolchildren (50.7% male) aged 11-15 who responded to the Smoking Drinking and Drug Use among Young People surveys. MEASUREMENTS: Past-week alcohol consumption in UK units at each fifth percentile of the consumption distribution. FINDINGS: Reductions in alcohol consumption occurred at all percentiles of the consumption distribution analysed between 2001 and 2016, but the magnitude of the decline differed across percentiles. The decline in consumption at the 90th percentile [ß = -0.21, confidence interval (CI) = -0.24, -0.18] was significantly larger than among either lighter drinkers at the 50th percentile (ß = -0.02, CI = -0.02, -0.01) or heavier drinkers at the 95th percentile (ß = -0.16, CI = -0.18, -0.13). CONCLUSIONS: Alcohol consumption among young people in England appears to be declining across the consumption distribution, and peaks among heavy drinkers. The magnitude of this decline differs significantly between percentiles of the consumption distribution, with consumption falling proportionally less among the lightest, moderate and very heaviest youth drinkers.

Prognostic Factors in Patients with Persistent Full-Thickness Idiopathic Macular Holes Treated with Re-Vitrectomy with Autologous Platelet Concentrate.

PURPOSE: To identify the predictors for anatomical and functional outcome after re-vitrectomy with application of autologous platelet concentrate (APC) in eyes with persistent idiopathic macular hole (MH). METHODS: Retrospective study of 103 eyes with persistent MHs after vitrectomy with peeling of internal limiting membrane (ILM) and expansive gas. All patients underwent re-vitrectomy with APC and endotamponade. The anatomical MH closure rate and postoperative best-corrected visual acuity (BCVA) were evaluated. Further, predictive factors influencing the success of the surgery were analyzed. RESULTS: Median BCVA (logMAR) before the surgery was 1.00 (interquartile range [IQR] 0.80-1.30) and the median of minimum diameter between hole edges was 508 µm (IQR 387-631). The final closure rate after re-vitrectomy with APC was 60.2% (62 of 103 eyes). The following predictors were identified to significantly influence the closure rate: tractional hole index (THI), axial length, time between first and second surgery, and the experience of the surgeon (p < 0.05). CONCLUSIONS: Re-vitrectomy with APC led to the closure of 60.2% of the persistent MHs. The closure rate negatively correlates with increasing axial length, time between the first and second surgery, and the decreased THI. Further, experienced surgeons (with a history of >100 pars plana vitrectomies with ILM peeling) had significantly higher closure rates.

Population Pharmacokinetics of Intraperitoneal Bupivacaine Using Manual Bolus Atomization Versus Micropump Nebulization and Morphine Requirements in Young Children.

BACKGROUND: Intraperitoneal (IP) administration of local anesthetics is used in adults and children for postoperative analgesia after laparoscopic surgery. Population pharmacokinetics (PK) of IP bupivacaine has not been determined in children. Objectives of this study were (1) to develop a population PK model to compare IP bupivacaine administered via manual bolus atomization and micropump nebulization and (2) to assess postoperative morphine requirements after intraoperative administration. We hypothesized similar PK profiles and morphine requirements for both delivery methods. METHODS: This was a prospective, sequential, observational study. After institutional review board (IRB) approval and written informed parental consent, 67 children 6 months to 6 years of age undergoing robot-assisted laparoscopic urological surgery received IP bupivacaine at the beginning of surgery. Children received a total dose of 1.25 mg/kg bupivacaine, either diluted in 30-mL normal saline via manual bolus atomization over 30 seconds or undiluted bupivacaine 0.5% via micropump nebulization into carbon dioxide (CO2) insufflation tubing over 10-17.4 minutes. Venous blood samples were obtained at 4 time points between 1 and 120 minutes intraoperatively. Samples were analyzed by liquid chromatography with mass spectrometry. PK parameters were calculated using noncompartmental and compartmental analyses. Nonlinear regression modeling was used to estimate PK parameters (primary outcomes) and Mann-Whitney U test for morphine requirements (secondary outcomes). RESULTS: Patient characteristics between the 2 delivery methods were comparable. No clinical signs of neurotoxicity or cardiotoxicity were observed. The range of peak plasma concentrations was 0.39-2.44 µg/mL for the manual bolus atomization versus 0.25-1.07 µg/mL for the micropump nebulization. IP bupivacaine PK was described by a 1-compartment model for both delivery methods. Bupivacaine administration by micropump nebulization resulted in a significantly lower Highest Plasma Drug Concentration (Cmax) and shorter time to reach Cmax (Tmax) (P < .001) compared to manual bolus atomization. Lower plasma concentrations with less interpatient variability were observed and predicted by the PK model for the micropump nebulization (P < .001). Adjusting for age, weight, and sex as covariates, Cmax and area under the curve (AUC) were significantly lower with micropump nebulization (P < .001). Regardless of the delivery method, morphine requirements were low at all time points. There were no differences in cumulative postoperative intravenous/oral morphine requirements between manual bolus atomization and micropump nebulization (0.14 vs 0.17 mg/kg; P = .85) measured up to 24 hours postoperatively. CONCLUSIONS: IP bupivacaine administration by micropump nebulization demonstrated lower plasma concentrations, less interpatient variability, low risk of toxicity, and similar clinical efficacy compared to manual bolus atomization. This is the first population PK study of IP bupivacaine in children, motivating future randomized controlled trials to determine efficacy.

Socioeconomic inequalities in the delivery of brief interventions for smoking and excessive drinking: findings from a cross-sectional household survey in England.

OBJECTIVES: Brief interventions (BI) for smoking and risky drinking are effective and cost-effective policy approaches to reducing alcohol harm currently used in primary care in England; however, little is known about their contribution to health inequalities. This paper aims to investigate whether self-reported receipt of BI is associated with socioeconomic position (SEP) and whether this differs for smoking or alcohol. DESIGN: Population survey of 8978 smokers or risky drinkers in England aged 16+ taking part in the Alcohol and Smoking Toolkit Studies. MEASURES: Survey participants answered questions regarding whether they had received advice and support to cut down their drinking or smoking from a primary healthcare professional in the past 12 months as well as their SEP, demographic details, whether they smoke and their motivation to cut down their smoking and/or drinking. Respondents also completed the Alcohol Use Disorders Identification Test (AUDIT). Smokers were defined as those reporting any smoking in the past year. Risky drinkers were defined as those scoring eight or more on the AUDIT. RESULTS: After adjusting for demographic factors and patterns in smoking and drinking, BI delivery was highest in lower socioeconomic groups. Smokers in the lowest social grade had 30% (95% CI 5% to 61%) greater odds of reporting receipt of a BI than those in the highest grade. The relationship for risky drinking appeared stronger, with those in the lowest social grade having 111% (95% CI 27% to 252%) greater odds of reporting BI receipt than the highest grade. Rates of BI delivery were eight times greater among smokers than risky drinkers (48.3% vs 6.1%). CONCLUSIONS: Current delivery of BI for smoking and drinking in primary care in England may be contributing to a reduction in socioeconomic inequalities in health. This effect could be increased if intervention rates, particularly for drinking, were raised.

[Pediatric Retinal Detachment]. / Netzhautablösung im Kindesalter.

The number of retinal detachments in children is rarely compared to the number of retinal detachments in adults; only 3 - 7% occur in children. The main predisposing factors are trauma, myopia, hereditary vitreoretinopathies, retinopathy of prematurity, malformations and Coats' disease. The most frequent paediatric retinal detachments are trauma-associated and vitreoretinopathies are the most common cause of inherited retinal detachment. Disease-specific surgical treatments are discussed. Episcleral buckling surgery should be the preferred method in any case of clear lens, especially for treatment of oradialysis and well-defined localization of peripherally retinal tears. In those suffering from vitreoretinopathy, primary vitrectomy is necessary. The intravitreal use of VEGF-inhibitors to treat vasoproliferative retinopathy in children is a new and effective tool, but we need further results about safety and side-effects in young patients. The functional and anatomical outcomes of retinal detachment in children are less successful than in adults. Further surgical innovations and etiology-specific treatment strategies are required to improve the outcome in this group.

Endoscopic Versus Open Repair for Craniosynostosis in Infants Using Propensity Score Matching to Compare Outcomes: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The North American Pediatric Craniofacial Collaborative Group (PCCG) established the Pediatric Craniofacial Surgery Perioperative Registry to evaluate outcomes in infants and children undergoing craniosynostosis repair. The goal of this multicenter study was to utilize this registry to assess differences in blood utilization, intensive care unit (ICU) utilization, duration of hospitalization, and perioperative complications between endoscopic-assisted (ESC) and open repair in infants with craniosynostosis. We hypothesized that advantages of ESC from single-center studies would be validated based on combined data from a large multicenter registry. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. We analyzed 1382 infants younger than 12 months undergoing open (anterior and/or posterior cranial vault reconstruction, modified-Pi procedure, or strip craniectomy) or endoscopic craniectomy. The primary outcomes included transfusion data, ICU utilization, hospital length of stay, and perioperative complications; secondary outcomes included anesthesia and surgical duration. Comparison of unmatched groups (ESC: N = 311, open repair: N = 1071) and propensity score 2:1 matched groups (ESC: N = 311, open repair: N = 622) were performed by conditional logistic regression analysis. RESULTS: Imbalances in baseline age and weight are inherent due to surgical selection criteria for ESC. Quality of propensity score matching in balancing age and weight between ESC and open groups was assessed by quintiles of the propensity scores. Analysis of matched groups confirmed significantly reduced utilization of blood (26% vs 81%, P < .001) and coagulation (3% vs 16%, P < .001) products in the ESC group compared to the open group. Median blood donor exposure (0 vs 1), anesthesia (168 vs 248 minutes) and surgical duration (70 vs 130 minutes), days in ICU (0 vs 2), and hospital length of stay (2 vs 4) were all significantly lower in the ESC group (all P < .001). Median volume of red blood cell administered was significantly lower in ESC (19.6 vs 26.9 mL/kg, P = .035), with a difference of approximately 7 mL/kg less for the ESC (95% confidence interval for the difference, 3-12 mL/kg), whereas the median volume of coagulation products was not significantly different between the 2 groups (21.2 vs 24.6 mL/kg, P = .73). Incidence of complications including hypotension requiring treatment with vasoactive agents (3% vs 4%), venous air embolism (1%), and hypothermia, defined as <35°C (22% vs 26%), was similar between the 2 groups, whereas postoperative intubation was significantly higher in the open group (2% vs 10%, P < .001). CONCLUSIONS: This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.

All drinking is not equal: how a social practice theory lens could enhance public health research on alcohol and other health behaviours.

BACKGROUND: The social meanings, settings and habitual nature of health-related activities and their integration into our daily lives are often overlooked in quantitative public health research. This reflects an overly individualized approach to epidemiological surveillance and evaluations of public health interventions, based on models of behaviour that are rooted in social cognition and rational choice theories. This paper calls for a new approach to alcohol epidemiology and intervention research informed by theories of practice. ARGUMENT: Practices are conceptualized as routinized types of human activity that are made up of, and can be recognized by, the coming together of several interwoven elements in the same situation (e.g. materials, meanings, skills, locations, timings). Different practices are interconnected-they can occur simultaneously (e.g. drinking and eating), hold each other in place (e.g. after-work drinks) or compete for time (e.g. parenting versus socializing). Applying these principles to alcohol research means shifting attention away from individuals and their behaviours and instead making drinking practices an important unit of analysis. Studying how drinking practices emerge, persist and decay over time, how they spread through populations and local or social networks and how they relate to other activities of everyday life promises new insights into how, why, where, when and with whom drinking and getting drunk occur. CONCLUSIONS: Theories of practice provide a framework for generating new explanations of stability and change in alcohol consumption and other health behaviours. This framework offers potential for novel insights into the persistence of health inequalities, unanticipated consequences of policies and interventions and new interventions targets through understanding which elements of problematic practices are likely to be most modifiable. We hope this will generate novel insights into the emergence and decay of drinking practices over time and into the geographical and socio-demographic patterning of drinking. Theories of practice-informed research would consider how alcohol policies and population-level interventions might differentially affect different drinking practices.

A novel bovine papillomavirus type in the genus Dyokappapapillomavirus.

Papillomaviruses are a diverse group of viruses that are known to infect a wide range of animal species. Bovine papillomaviruses (BPVs) are divided into at least 21 genotypes (BPV1 to BPV21),  with most BPV isolates/strains described to date belonging to one of four genera, including Deltapapillomavirus, Xipapillomavirus, Epsilonpapillomavirus and Dyoxipapillomavirus. Here, we describe the identification and genetic characterization of a new BPV type in the genus Dyokappapapillomavirus. A farm in the state of New York, USA, reported chronic cases of vulvovaginitis in Holstein cows in 2016. Biopsies and/or swab samples collected from the vaginal mucosa were subjected to diagnostic investigation. Conventional diagnostic assays yielded negative results, and vaginal swab samples were subjected to viral metagenomic sequencing. Notably, BLAST searches revealed a papillomavirus genome with 7480 bp in length (67% nt sequence identity to BPV16). Additionally, phylogenetic analysis of the L1 gene of the papillomavirus identified here (tentatively named BPV22) revealed that it clusters with members of the genus Dyokappapapillomavirus. Interestingly, the recently identified BPV16, which was detected in fibropapilloma lesions in cattle also clusters within the Dyokappapapillomavirus group. Each virus, however, forms a separate branch in the phylogenetic tree. These results indicate that the putative BPV22 represents the second BPV within the genus Dyokappapapillomavirus.

Understanding the alcohol harm paradox: an analysis of sex- and condition-specific hospital admissions by socio-economic group for alcohol-associated conditions in England.

BACKGROUND AND AIMS: In many countries, conflicting gradients in alcohol consumption and alcohol-associated mortality have been observed. To understand this 'alcohol harm paradox' we analysed the socio-economic gradient in alcohol-associated hospital admissions to test whether it was greater in conditions which were: (1) chronic (associated with long-term drinking) and partially alcohol-attributable, (2) chronic and wholly alcohol-attributable, (3) acute (associated with intoxication) and partially alcohol-attributable and (4) acute and wholly alcohol-attributable. Our aim was to clarify how (1) drinking patterns (e.g. intoxication linked to acute admissions or dependence linked to chronic conditions) and (2) non-alcohol causes (e.g. smoking and poor diet which are risks for partially alcohol-attributable conditions) contribute to the paradox. DESIGN: Regression analysis testing the modifying effects of condition-group (1-4 above) and sex on the relationship between area-based deprivation and admissions. SETTING: England, April 2010-March 2013. PARTICIPANTS: A total of 9 239 629 English hospital admissions where a primary or secondary cause was one of 36 alcohol-associated conditions. MEASUREMENTS: Admissions by condition and deciles of Index of Multiple Deprivation (IMD). Socio-economic gradient measured as the relative index of inequality (RII, the slope of a linear regression of IMD on admissions adjusted for overall admission rate). Conditions were categorized by ICD-10 code. FINDINGS: A socio-economic gradient in hospitalizations was seen for all conditions, except partially attributable chronic conditions. The gradient was significantly steeper for conditions which were wholly attributable to alcohol and for acute conditions than for conditions partially alcohol-attributable and for chronic conditions. Gradients were steeper for men than for women in cases of wholly alcohol attributable conditions. CONCLUSIONS: There is a socio-economic gradient in English hospital admission for most alcohol-associated conditions. The greatest inequalities are in conditions associated with alcohol dependence, such as liver disease and mental and behavioural conditions, and in acute conditions, such as alcohol poisoning and assault. Socio-economic differences in harmful drinking patterns (dependence and intoxication) may contribute to the 'alcohol harm paradox'.

Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes. RESULTS: One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable. CONCLUSIONS: The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.

Use of aids for smoking cessation and alcohol reduction: A population survey of adults in England.

BACKGROUND: It is important for policy planning to chart the methods smokers and high-risk drinkers use to help them change their behaviour. This study assessed prevalence of use, and characteristics of users, of support for smoking cessation and alcohol reduction in England. METHODS: Data were used from the Smoking and Alcohol Toolkit Studies, which involve monthly face-to-face computer-assisted interviews of adults aged 16+ in England. We included data collected between June 2014 and July 2015 on 1600 smokers who had made at least one quit attempt and 911 high-risk drinkers (defined as scores >8+ on the full AUDIT or 5+ on questions 1-3 of the AUDIT-C) who had made an attempt to cut down in the past 12 months. Participants provided information on their socio-demographic characteristics and use of aids during their most recent quit attempt including pharmacotherapy, face-to-face counselling, telephone support, self-help materials (digital and printed), and complementary medicine. RESULTS: A total of 60.3% of smokers used aids in the past year, compared with just 14.9% of high-risk drinkers. Use of pharmacotherapy was high among smokers and very low among drinkers (56.0%versus1.2%). Use of other aids was low for both behaviours: face-to-face counselling (2.6%versus4.8%), self-help materials (1.4%versus4.1%) and complementary medicine (1.0%versus0.5%). Use of aids was more common among smokers aged 25-54 compared with 16-24 year olds (25-34,ORadj1.49,p = 0.012; 35-44,ORadj1.93,p < 0.001; 35-44,ORadj1.93,p < 0.001; 45-54,ORadj1.66,p = 0.008), with cigarette consumption >10 relative to <1 (10-20,ORadj2.47,p = 0.011; >20,ORadj4.23,p = 0.001), and less common among ethnic minorities (ORadj0.69,p = 0.026). For alcohol reduction, use of aids was higher among ethnic minority groups (ORadj2.41;p = 0.015), and those of social-grade D/E relative to AB (ORadj2.29,p = 0.012&ORadj3.13,p < 0.001). CONCLUSION: In England, the use of pharmacotherapy is prevalent for smoking cessation but not alcohol reduction. Other aids are used at a low rate, with face-to-face counselling being more common for alcohol reduction than smoking cessation.

Public awareness of the link between alcohol and cancer in England in 2015: a population-based survey.

BACKGROUND: Public knowledge of the association between alcohol and cancer is reported to be low. We aimed to provide up-to-date evidence for England regarding awareness of the link between alcohol and different cancers and to determine whether awareness differs by demographic characteristics, alcohol use, and geographic region. METHODS: A representative sample of 2100 adults completed an online survey in July 2015. Respondents were asked to identify which health outcomes, including specific cancers, may be caused by alcohol consumption. Logistic regressions explored whether demographic, alcohol use, and geographic characteristics predicted correctly identifying alcohol-related cancer risk. RESULTS: Unprompted, 12.9% of respondents identified cancer as a potential health outcome of alcohol consumption. This rose to 47% when prompted (compared to 95% for liver disease and 73% for heart disease). Knowledge of the link between alcohol and specific cancers varied between 18% (breast) and 80% (liver). Respondents identified the following cancers as alcohol-related where no such evidence exists: bladder (54%), brain (32%), ovarian (17%). Significant predictors of awareness of the link between alcohol and cancer were being female, more highly educated, and living in North-East England. CONCLUSION: There is generally low awareness of the relationship between alcohol consumption and cancer, particularly breast cancer. Greater awareness of the relationship between alcohol and breast cancer in North-East England, where a mass media campaign highlighted this relationship, suggests that population awareness can be influenced by social marketing.

Multivariable predictors of substantial blood loss in children undergoing craniosynostosis repair: implications for risk stratification.

BACKGROUND: Operative treatment of craniosynostosis is associated with substantial blood loss, often requiring transfusion of packed red blood cells (PRBC) and coagulation products. AIMS: The aim of this prospective study was to analyze thromboelastographic (TEG) parameters and platelet fibrinogen product to determine predictors of substantial blood loss, and the need for PRBC transfusion and coagulation products. METHODS: With IRB approval, we enrolled 120 children undergoing craniosynostosis repair with a standardized anesthetic, fluid management, and TEG measurements at predefined times. Outcomes of interest were intraoperative blood loss, and need for PRBC transfusion and coagulation products. Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis was applied to determine independent predictors of substantial blood loss and need for coagulation products. RESULTS: One hundred and eighteen children were included in the analysis. Forty-four required PRBC transfusion (median 26 ml·kg(-1) ; IQR: 22-42) with median blood loss of 56 ml·kg(-1) (IQR: 43-83). Factors associated with the PRBC transfusion included type of surgery, duration of surgery, and three TEG parameters, α-angle, MA, and K-time (all P < 0.001). A predictive algorithm was developed by subgroup analysis of cranial vault reconstruction (CVR) patients for substantial intraoperative blood loss (defined as ≥60 ml·kg(-1) ) and need for coagulation products with ROC-derived cut-off values: platelet fibrinogen product, <343; α-angle, <62°; MA, <55 mm; K-time, >2.1 min. The best prognostic combination included at least two of these four predictors (sensitivity 89%, specificity 90%). Multivariable regression identified MA as the only independent predictor of coagulation product administration (P < 0.001) and ROC analysis identified MA <46 mm as the optimal cut-off (sensitivity 86%, specificity 94%). CONCLUSIONS: Risk for substantial intraoperative blood loss can be assessed using TEG parameters and platelet fibrinogen product, whereas the need for coagulation products is strongly related to low MA. Patients susceptible to substantial blood loss can be risk stratified based on their TEG/platelet fibrinogen product profile.