Barriers and enablers of implementation of alcohol guidelines with pregnant women: a cross-sectional survey among UK midwives.

BACKGROUND: In 2016, the UK Chief Medical Officers revised their guidance on alcohol and advised women to abstain from alcohol if pregnant or planning pregnancy. Midwives have a key role in advising women about alcohol during pregnancy. The aim of this study was to investigate UK midwives' practices regarding the 2016 Chief Medical Officers Alcohol Guidelines for pregnancy, and factors influencing their implementation during antenatal appointments. METHODS: Online cross-sectional survey of a convenience sample of UK midwives recruited through professional networks and social media. Data were gathered using an anonymous online questionnaire addressing knowledge of the 2016 Alcohol Guidelines for pregnancy; practice behaviours regarding alcohol assessment and advice; and questions based on the Theoretical Domains Framework (TDF) to evaluate implementation of advising abstinence at antenatal booking and subsequent antenatal appointments. RESULTS: Of 842 questionnaire respondents, 58% were aware of the 2016 Alcohol Guidelines of whom 91% (438) cited abstinence was recommended, although 19% (93) cited recommendations from previous guidelines. Nonetheless, 97% of 842 midwives always or usually advised women to abstain from alcohol at the booking appointment, and 38% at subsequent antenatal appointments. Mean TDF domain scores (range 1-7) for advising abstinence at subsequent appointments were highest (indicative of barriers) for social influences (3.65 sd 0.84), beliefs about consequences (3.16 sd 1.13) and beliefs about capabilities (3.03 sd 073); and lowest (indicative of facilitators) for knowledge (1.35 sd 0.73) and professional role and identity (1.46 sd 0.77). Logistic regression analysis indicated that the TDF domains: beliefs about capabilities (OR = 0.71, 95% CI: 0.57, 0.88), emotion (OR = 0.78; 95%CI: 0.67, 0.90), and professional role and identity (OR = 0.69, 95%CI 0.51, 0.95) were strong predictors of midwives advising all women to abstain from alcohol at appointments other than at booking. CONCLUSIONS: Our results suggest that skill development and reinforcement of support from colleagues and the wider maternity system could support midwives' implementation of alcohol advice at each antenatal appointment, not just at booking could lead to improved outcomes for women and infants. Implementation of alcohol care pathways in maternity settings are beneficial from a lifecourse perspective for women, children, families, and the wider community.

Exploring gender differences among treatment-seekers who use opioids versus alcohol and other drugs.

Identifying clinical differences between opioid users (OU) and alcohol and other drug users (AOD) may help to tailor treatment to OU, particularly among the majority of OU who are not on opioid agonist treatments. Given the dearth of research on these differences, this study explored gender differences in demographic and clinical characteristics between OU and AOD. Participants (N = 506) were from a multisite, randomized controlled clinical trial of an Internet-delivered psychosocial intervention conducted in 2010-2011. Logistic regression models explored differences in demographic and clinical characteristics by substance use category within and between women and men. Women OU were more likely to be younger, White, employed, benzodiazepine users, and less likely to have children or use cocaine and cannabis than women AOD. Men OU, compared to men AOD, were more likely to be younger, White, younger at first abuse/dependence, benzodiazepine users, and reported greater psychological distress, but were less likely to be involved in criminal justice or use stimulants. Interactions by gender and substance use were also detected for age of first abuse/dependence, employment, and criminal justice involvement. These findings provide a nuanced understanding of gender differences within substance use groups to inform providers for OU seeking treatment.

Development of a joint mental-health and drug health assessment unit and short-stay unit.

OBJECTIVES: There is emerging interest in models of care that focus on assessment and brief inpatient treatment (two to three days) including psychiatric emergency care centre units and short-stay units in Australia. We present the development of a functionally integrated Missenden Assessment Unit and six-bed short-stay unit in the new Professor Marie Bashir Centre at Royal Prince Alfred Hospital in inner-city Sydney. The focus was on collaboration between emergency, drug and alcohol and mental-health services in developing the short-stay unit and Missenden Assessment Unit with joint admission and resource use. We outline the models of care and findings from the 2016 evaluation following the initial two years of operation and consider ongoing challenges. CONCLUSION: The Missenden Assessment Unit provides an alternative point of presentation for mental-health drug and alcohol patients. The short-stay unit provides coordinated, therapeutic interventions. The Missenden Assessment Unit/short-stay unit reduced the burden of presentations to the emergency department while providing the opportunity for training and collaboration. Further refinement of the models of care should occur with policy development and via research.

Impaired affective prosody decoding in severe alcohol use disorder and Korsakoff syndrome.

Recognizing others' emotions is a fundamental social skill, widely impaired in psychiatric populations. These emotional dysfunctions are involved in the development and maintenance of alcohol-related disorders, but their differential intensity across emotions and their modifications during disease evolution remain underexplored. Affective prosody decoding was assessed through a vocalization task using six emotions, among 17 patients with severe alcohol use disorder, 16 Korsakoff syndrome patients (diagnosed following DSM-V criteria) and 19 controls. Significant disturbances in emotional decoding, particularly for negative emotions, were found in alcohol-related disorders. These impairments, identical for both experimental groups, constitute a core deficit in excessive alcohol use.

Posttreatment Low-Risk Drinking as a Predictor of Future Drinking and Problem Outcomes Among Individuals with Alcohol Use Disorders: A 9-Year Follow-Up.

BACKGROUND: Treatment for alcohol use disorders (AUDs) has traditionally been abstinence oriented, but new research and regulatory guidelines suggest that low-risk drinking may also be an acceptable treatment outcome. However, little is known about long-term outcomes for patients who become low-risk drinkers posttreatment. This study explores a posttreatment low-risk drinking outcome as a predictor of future drinking and psychosocial outcomes over 9 years. METHODS: Study participants were adults with AUDs at treatment entry who received follow-up interviews 6 months posttreatment intake (N = 1,061) in 2 large randomized studies conducted at Kaiser Permanente Northern California, a large private, nonprofit, integrated health system. Six-month drinking status was defined as abstinent, low-risk (nonabstinent, no 5+ drinking days), or heavy drinking (1 or more days of 5+ drinks). Using logistic regression models, we explored the relationship between past 30-day drinking status at 6 months and odds of being abstinent or a low-risk drinker (compared to heavy drinking), and positive Addiction Severity Index psychosocial outcomes over 9 years (9-year follow-up rate of 73%). RESULTS: Abstainers and low-risk drinkers at 6 months had higher odds of recent abstinence/low-risk drinking over 9 years than heavy drinkers; abstainers had better drinking outcomes than low-risk drinkers. Additionally, among those with interview data, 95% of abstainers and 94% of low-risk drinkers at 6 months were abstinent/low-risk drinkers at 9 years; surprisingly, 89% of heavy drinkers at 6 months were also abstinent/low-risk drinkers although still significantly fewer than the other groups. Abstainers and low-risk drinkers at 6 months had better psychiatric outcomes, and abstainers had better family/social outcomes than heavy drinkers; medical outcomes did not differ. Low-risk drinkers and abstainers showed no reliable differences across psychosocial measures. CONCLUSIONS: The findings suggest that a low-risk drinking outcome may be reasonable over the long-term for some alcohol-dependent individuals receiving addiction treatment.

Efficacy of transcranial direct current stimulation (tDCS) in reducing consumption in patients with alcohol use disorders: study protocol for a randomized controlled trial.

BACKGROUND: Approximately 15 million persons in the European Union and 10 million persons in the USA are alcohol-dependent. The global burden of disease and injury attributable to alcohol is considerable: worldwide, approximately one in 25 deaths in 2004 was caused by alcohol. At the same time, alcohol use disorders remain seriously undertreated. In this context, alternative or adjunctive therapies such as brain stimulation may play a prominent role. The early results of studies using transcranial direct current stimulation found that stimulations delivered to the dorsolateral prefrontal cortex result in a significant reduction of craving and an improvement of the decision-making processes in various additive disorders. We, therefore, hypothesize that transcranial direct current stimulation can lead to a decrease in alcohol consumption in patients suffering from alcohol use disorders. METHODS/DESIGN: We report the protocol of a randomized, double-blind, placebo-controlled, parallel-group trial, to evaluate the efficacy of transcranial direct current stimulation on alcohol reduction in patients with an alcohol use disorder. The study will be conducted in 14 centers in France and Monaco. Altogether, 340 subjects over 18 years of age and diagnosed with an alcohol use disorder will be randomized to receive five consecutive twice-daily sessions of either active or placebo transcranial direct current stimulation. One session consists in delivering a current flow continuously (anode F4; cathode F3) twice for 13 minutes, with treatments separated by a rest interval of 20 min. Efficacy will be evaluated using the change from baseline (alcohol consumption during the 4 weeks before randomization) to 24 weeks in the total alcohol consumption and number of heavy drinking days. Secondary outcome measures will include alcohol craving, clinical and biological improvements, and the effects on mood and quality of life, as well as cognitive and safety assessments, and, for smokers, an assessment of the effects of transcranial direct current stimulation on tobacco consumption. DISCUSSION: Several studies have reported a beneficial effect of transcranial direct current stimulation on substance use disorders by reducing craving, impulsivity, and risk-taking behavior, and suggest that transcranial direct current stimulation may be a promising treatment in addiction. However, to date, no studies have included sufficiently large samples and sufficient follow-up to confirm the hypothesis. Results from this large randomized controlled trial will give a better overview of the therapeutic potential of transcranial direct current stimulation in alcohol use disorders. TRIAL REGISTRATION: Clinical Trials Gov, NCT02505126 (registration date: July 15 2015).

Factors Affecting the Downward Mobility of Psychiatric Patients: A Korean Study of National Health Insurance Beneficiaries.

OBJECTIVES: The purpose of this study is to examine the magnitude of and the factors associated with the downward mobility of first-episode psychiatric patients. METHODS: This study used the claims data from the Korean Health Insurance Review and Assessment Service. The study population included 19 293 first-episode psychiatric inpatients diagnosed with alcohol use disorder (International Classification of Diseases, 10th revision [ICD-10] code F10), schizophrenia and related disorders (ICD-10 codes F20-F29), and mood disorders (ICD-10 codes F30-F33) in the first half of 2005. This study included only National Health Insurance beneficiaries in 2005. The dependent variable was the occurrence of downward mobility, which was defined as a health insurance status change from National Health Insurance to Medical Aid. Logistic regression analysis was used to assess factors associated with downward drift of first-episode psychiatric patients. RESULTS: About 10% of the study population who were National Health Insurance beneficiaries in 2005 became Medical Aid recipients in 2007. The logistic regression analysis showed that age, gender, primary diagnosis, type of hospital at first admission, regular use of outpatient clinic, and long-term hospitalization are significant predictors in determining downward drift in newly diagnosed psychiatric patients. CONCLUSIONS: This research showed that the downward mobility of psychiatric patients is affected by long-term hospitalization and medical care utilization. The findings suggest that early intensive intervention might reduce long-term hospitalization and the downward mobility of psychiatric patients.

The Effectiveness of Visual Short-Time Neurofeedback on Brain Activity and Clinical Characteristics in Alcohol Use Disorders: Practical Issues and Results.

The present study was carried out to examine the efficacy of alpha/theta neurofeedback (NF) with a new visual paradigm in a cohort of alcohol use disordered (AUD) patients (n = 25) treated in an Austrian therapeutic community center. The experimental study design focused on changes in absolute and relative resting EEG band power as well as in clinical variables, including depression (Beck Depresion Inventory [BDI-V]), psychiatric symptoms (Brief Symptom Inventory [BSI], coping (Freiburg Questionnaire on Coping with Illness [FKV-lis]), psychotherapy motivation (Therapy Motivation Questionnaire [FPTM-23]), sense of coherence (Sense of Coherence Scale [SOC-13]), posttraumatic growth (Posttraumatic Growth Inventory [PPR]), and alcohol cravings (Alcohol Craving Questionnaire [ACQ]). For measuring training effects, participants were randomly allocated to 2 groups: an experimental group (EG, n = 13) and a control group (CG, n = 12). Patients in EG received 12 sessions of visual NF training over a period of 6 weeks to enhance alpha (8-12 Hz) and theta (4-7 Hz) frequency band power in addition to the standard treatment program of the rehabilitation center. Participants in CG received no additional NF intervention. The multivariate analysis of covariance (MANCOVA) showed a change by trend in absolute alpha and theta power in the EG. Even though no MANCOVA effects were found in the clinical scales, AUD patients reported increasing control of their brain activity during the course of NF. However, changes in several clinical scales (BDI-V, BSI, FKV-lis, PPR) from pre- to posttest were observed only in the EG contrary to the CG. The findings of this pilot study provide first evidence for the practicality and effectiveness of visual short-term NF as an additive intervention in the therapeutic community.

Treatment outcome for adolescents abusing alcohol and cannabis: how many 'reliably improve'?

Alcohol and cannabis are the primary substances contributing to referrals of adolescents to substance abuse treatment services. Their outcome has not been examined in Ireland. A three month follow-up was conducted in an outpatient adolescent treatment program. We followed up 35 high risk users of alcohol and 55 high risk users of cannabis. Although the high risk drinkers achieved a significant reduction in median number of days drinking (p = 0.004), only four (11 %) were abstinent at follow up. A further five (14%) achieved a reliable reduction in days of drinking. The high risk cannabis users demonstrated a significant drop in median days of use (p < 0.001), although only six (11%) were abstinent at follow up. A further 20 (36%) achieved a reliable reduction in days of use. Calculation of reliable change allows examination of outcomes which fall short of the elusive goal of abstinence.

Using Interactive Web-Based Screening, Brief Intervention and Referral to Treatment in an Urban, Safety-Net HIV Clinic.

Substance use among people living with HIV is high, and screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based approach to addressing the issue. We examined whether patients would participate in a technology-based SBIRT program in an urban HIV clinic. An SBIRT intervention was programmed into the clinic's web-based patient portal linked to their personal health record. We examined: demographic, health, HIV, and substance use characteristics of participants who completed the web-based intervention compared to those who did not. Fewer than half of the 96 participants assigned to the web-based SBIRT completed it (n = 39; 41 %). Participants who completed the web-based intervention had significantly higher amphetamine SSIS scores than those who did not complete the intervention. Participants whose substance use is more harmful may be more motivated to seek help from a variety of sources. In addition, it is important that technology-based approaches to behavioral interventions in clinics take into consideration feasibility, client knowledge, and comfort using technology.

Alcohol brief interventions in Scottish antenatal care: a qualitative study of midwives' attitudes and practices.

BACKGROUND: Infants exposed to alcohol in the womb are at increased risk of experiencing health problems. However, mixed messages about the consequences of prenatal alcohol consumption have resulted in inconsistent attitudes and practices amongst some healthcare practitioners. Screening and alcohol brief interventions (ABIs) can reduce risky drinking in various clinical settings. Recently, a program of screening and ABIs have been implemented in antenatal care settings in Scotland. However, current evidence suggests that midwives' involvement in alcohol brief interventions activities is patchy. This study explored midwives' attitudes and practices regarding alcohol screening and ABIs in order to understand why they are relatively underutilized in antenatal care settings compared to other clinical settings. METHODS: This was a qualitative study, involving semi-structured interviews with 15 midwives and a focus group with a further six midwifery team leaders (21 participants in total) in Scotland. Interview transcripts were analysed using thematic analysis. RESULTS: Midwives were positive about their involvement in the screening and ABI program. However, they were not completely convinced about the purpose and value of the screening and ABIs in antenatal care. In the midst of competing priorities, the program was seen as having a low priority in their workload. Midwives felt that the rapport between them and pregnant women was not sufficiently established at the first antenatal appointment to allow them to discuss alcohol issues appropriately. They reported that many women had already given up drinking or were drinking minimal amounts prior to the first antenatal appointment. CONCLUSIONS: Midwives recognised the important role they could play in alcohol intervention activities in antenatal care. As the majority of women stop consuming alcohol in pregnancy, many will not need an ABI. Those who have not stopped are likely to need an ABI, but midwives were concerned that it was this group that they were most likely to alienate by discussing such concerns. Further consideration should be given to pre-pregnancy preventative measures as they are more likely to reduce alcohol-exposed pregnancies.

A special ventricular arrhythmia!

Alcohol is the most widely tolerated and consumed drug worldwide. Alcohol consumption is associated with both good and bad cardiovascular effects. The link between drinking alcohol and heart disease, or arrhythmia, in healthy individuals or with existing heart disease has been well demonstrated. We report the case of a patient with no evidence of heart disease who presented with sustained ventricular tachycardia and syncope after acute alcohol consumption. Alcohol is an uncommon and little-known cause of sustained ventricular tachycardia.

Evaluating brief screeners to discriminate between drug use disorders in a sample of treatment-seeking adults.

OBJECTIVE: The objective was to identify a potential core set of brief screeners for the detection of individuals with a substance use disorder (SUD) in medical settings. METHOD: Data were from two multisite studies that evaluated stimulant use outcomes of an abstinence-based contingency management intervention as an addition to usual care (National Drug Abuse Treatment Clinical Trials Network trials 006-007). The sample comprised 847 substance-using adults who were recruited from 12 outpatient substance abuse treatment settings across the United States. Alcohol and drug use disorders were assessed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Checklist. Data were analyzed by factor analysis, item response theory (IRT), sensitivity and specificity procedures. RESULTS: Comparatively prevalent symptoms of dependence, especially inability to cut down for all substances, showed high sensitivity for detecting an SUD (low rate of false negative). IRT-defined severe (infrequent) and low discriminative items, especially withdrawal for alcohol, cannabis and cocaine, had low sensitivity in identifying cases of an SUD. IRT-defined less severe (frequent) and high discriminative items, including inability to cut down or taking larger amounts than intended for all substances and withdrawal for amphetamines and opioids, showed good-to-high values of area under the receiver operating characteristic curve in classifying cases and noncases of an SUD. CONCLUSION: Findings suggest the feasibility of identifying psychometrically reliable substance dependence symptoms to develop a two-item screen for alcohol and drug disorders.

An electronic health record-enabled obesity database.

BACKGROUND: The effectiveness of weight loss therapies is commonly measured using body mass index and other obesity-related variables. Although these data are often stored in electronic health records (EHRs) and potentially very accessible, few studies on obesity and weight loss have used data derived from EHRs. We developed processes for obtaining data from the EHR in order to construct a database on patients undergoing Roux-en-Y gastric bypass (RYGB) surgery. METHODS: Clinical data obtained as part of standard of care in a bariatric surgery program at an integrated health delivery system were extracted from the EHR and deposited into a data warehouse. Data files were extracted, cleaned, and stored in research datasets. To illustrate the utility of the data, Kaplan-Meier analysis was used to estimate length of post-operative follow-up. RESULTS: Demographic, laboratory, medication, co-morbidity, and survey data were obtained from 2028 patients who had undergone RYGB at the same institution since 2004. Pre-and post-operative diagnostic and prescribing information were available on all patients, while survey laboratory data were available on a majority of patients. The number of patients with post-operative laboratory test results varied by test. Based on Kaplan-Meier estimates, over 74% of patients had post-operative weight data available at 4 years. CONCLUSION: A variety of EHR-derived data related to obesity can be efficiently obtained and used to study important outcomes following RYGB.

Diagnostic orphans for alcohol use disorders in a treatment-seeking psychiatric sample.

Individuals who endorse one or two of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criterion items for alcohol dependence but do not meet criteria for either alcohol abuse or dependence have been referred to in the literature as "diagnostic orphans." The goal of the present study is to compare diagnostic orphans for alcohol use disorders (AUD) to patients with lifetime DSM-IV alcohol abuse, alcohol dependence, and those with no-AUD symptoms on a series of demographic, diagnostic, and clinical measures. Participants were treatment-seeking psychiatric outpatients (n=1793; 61.5% women) who completed an in-depth, face-to-face diagnostic evaluation for DSM-IV axis I and axis II disorders. Results revealed that diagnostic orphans were younger, had a higher frequency of family history positive for alcoholism, and higher rates of cannabis dependence, as compared to the no-AUD symptoms group. Diagnostic orphans differed significantly from patients with alcohol abuse and dependence on a number of demographic, diagnostic, and clinical measures. Most notably, on a lifetime basis, diagnostic orphans were less likely to meet diagnostic criteria for various substance use disorders, as compared to individuals with alcohol abuse and dependence. Taken together, these results generally do not support combining diagnostic orphans to individuals with alcohol abuse.

Detecting alcohol-related problems among general hospital patients with heart disease.

BACKGROUND: Certain epidemiologic studies suggest that moderate alcohol consumption decreases the risk of coronary heart disease. However, long-term excessive alcohol drinking is considered a major cause for a significant incidence of heart disease. Identifying alcohol-related problems among inpatients with cardiac disease is important. METHODS: In this study, 209 male and 137 female inpatients with cardiac disease were screened for alcohol-related problems using the CAGE questionnaire. Associations of alcohol-related problems with sociodemographic and clinical variables were also investigated. RESULTS: Fifty-seven patients (16.5%) scoring positively on the CAGE questionnaire were considered as having alcohol-related problems. Logistic regression analysis revealed that alcohol-related problems were associated with sex (p = 0.00), age (p = 0.0497), and educational level (p = 0.0524). Men less than age 50, with cardiac disease and of lower education level should be considered at high risk for abnormal drinking. The probability increases from 5.2% for the whole sample to 41.9% for the group with these specific characteristics. CONCLUSIONS: The characteristics are useful for constructing a profile of the cardiology patient who is more likely to have alcohol-related problems. Early identification and vigorous and holistic treatment of these patients is important for secondary prevention of alcohol-related problems.

[Marchiafava-Bignami syndrome. Extrapontine myelinolysis in chronic alcoholism]. / Marchiafava-Bignami-Syndrom. Extrapontine Myelinolyse bei chronischem Alkoholmissbrauch.

Until now, the pathogenesis of Marchiafava-Bignami disease, an extrapontine myelinolysis, is unknown. Accept an abuse of alcohol for many years additional metabolic and vascular disturbances are supposed. The early performance of magnetic resonance imaging in patients with a sudden encephalopathy and history of alcoholism is essential for an assessment of the diagnosis. The bilateral lack of transcallosal inhibition--a parameter for the integrity of the transcallosal connections between motor cortices--is the consequence of the axonal degeneration of transcallosal fibers. Clinical and neuroradiological features of three patients with extrapontine myelinolysis are reported and possible etiologies of the complex disease are discussed. In two cases a severe alcohol abuse was present with the typical picture of the Marchiafava-Bignami disease. In a third patient an intoxication with methanol was present with a similar clinical picture. Although severe neurological disturbances were initially apparent in the patients, during the follow-up there was a significant amelioration of the clinical course under a high-dose vitamin B supplementation.