Does a place of last drink initiative affect the likelihood of alcohol sales to obviously intoxicated patrons?

BACKGROUND: Although the sale of alcohol to obviously intoxicated patrons (i.e., overservice) is illegal in 48 U.S. states, the likelihood of overservice at bars and restaurants has exceeded 80% across multiple studies, states, and decades. Place of last drink (POLD) enforcement is one proposed strategy to address alcohol overservice. When law enforcement agents respond to an alcohol-related incident, they ask the individuals involved where they had their last alcoholic beverage. POLD information is recorded and ideally systematically reviewed to identify locations that are frequently places of last drink. Law enforcement or other agencies may follow up with or penalize the alcohol license holder at these locations. We compared the likelihood of overservice in communities conducting POLD with communities that did not conduct POLD in Minnesota. METHODS: Pseudo-intoxicated patrons acted out signs of obvious intoxication while attempting to purchase alcohol at 396 bars and restaurants in 26 communities conducting POLD and 26 comparison communities. We calculated rates of alcohol sales to the pseudo-intoxicated patrons overall and in POLD communities versus comparison communities. RESULTS: The overall sales rate to the pseudo-intoxicated buyers was 98%. Rates of sales were 99% at establishments in POLD jurisdictions and 97% in comparison jurisdictions. There were no common characteristics, such as perceived gender/age of the server/bartender or crowdedness of the establishment, among the seven establishments that refused alcohol service. CONCLUSIONS: Our study shows that, as currently implemented in Minnesota, POLD does not reduce the overservice of alcohol at a jurisdiction level. More research is needed to identify interventions that yield sustained reductions in the overservice of alcohol.

The Interplay of Local- and State-Level Alcohol Policies in the US.

OBJECTIVE: Most research on alcohol control policies in the U.S. has focused on the state-level. In this study, we assessed both local and state policy prevalence and restrictiveness in a nationwide sample of cities. METHODS: We conducted original legal research to asses prevalence of local-level policies across 374 cities (48 states) in 2019 for seven policy areas: (1) Drink specials; (2) Beverage service training; (3) Minimum age for on-premise servers and bartenders; (4) Minimum age for off-premise sellers; (5) Prohibitions against hosting underage drinking parties (i.e., social host provisions); (6) Bans on off-premise Sunday sales; and (7) Keg registration. We obtained parallel state-level policies from the Alcohol Policy Information System. We assessed restrictiveness of existing policies and how these compared across local and state levels. RESULTS: We found that for six of the seven policy areas, the majority of cities (53% to 83%) had only a state-level policy. Few cities (0% to 8% across policy areas) had only a local-level policy. The percentage of cities that had an alcohol policy at both the local and state-level ranged from <1% to 19% across policy areas, and the policies were mostly equally restrictive at both levels. DISCUSSION: The lack of local policies may point to areas where these localities could strengthen their alcohol policy environments. More research is needed to understand how the prevalence and restrictiveness of local and state policies are associated with public health harms such as traffic crashes.

Alcohol Enforcement in the United States From 2010 to 2019.

OBJECTIVE: Despite the important role of enforcement in reducing alcohol-related harms, few studies have assessed alcohol enforcement efforts, particularly over time. We assessed the prevalence of alcohol law enforcement strategies at two time points. METHOD: Of a random sample of U.S. local law enforcement agencies (i.e., police, sheriff) surveyed in 2010, 1,028 were resurveyed in 2019 (742/1,028 [72%] response rate). We assessed changes in alcohol enforcement strategies and priorities within three domains: (a) alcohol-impaired driving, (b) alcohol sales to obviously intoxicated patrons (i.e., overservice), and (c) underage drinking. RESULTS: Agencies reported placing higher priority on enforcement of alcohol-impaired driving and overservice in 2019 versus 2010. For alcohol-impaired driving enforcement strategies, we found increases over time in use of saturation patrols and in enforcing laws prohibiting open containers of alcohol in motor vehicles, but not in use of sobriety checkpoints. Approximately 25% of agencies conducted overservice enforcement in both years. For all strategies directed at underage drinking, enforcement decreased over time with more agencies using strategies aimed at underage drinkers versus alcohol suppliers (alcohol outlets, adults) in both years. CONCLUSIONS: Agencies reported continued low levels or declines in enforcement across most strategies despite reported increases in prioritizing alcohol enforcement. More agencies could adopt alcohol control enforcement strategies, including an increased focus on suppliers of alcohol to youth rather than on underage drinkers, and increased awareness and enforcement of selling alcohol to obviously intoxicated patrons. Use of these strategies has the potential to reduce health and safety consequences of excessive alcohol use.

Place of last drink enforcement: Effects on alcohol-related traffic crashes.

BACKGROUND: Binge drinking can result in various types of harms including traffic crashes. Bars and restaurants that serve alcohol to patrons who are obviously intoxicated (i.e., overservice) contribute to these crashes. One strategy to address overservice is place of last drink (POLD) where law enforcement officers responding to alcohol-related incidents inquire about where the individuals last drank alcohol. This information may then be used to identify bars and restaurants that frequently overserve alcohol. There is limited evaluation of the effectiveness of POLD in reducing overservice, traffic crashes, and other harms. METHODS: We evaluated the effects of a POLD initiative, developed by some law enforcement agencies in Minnesota (USA), on alcohol-related traffic crashes from 2010 to 2019. Among 89 intervention (POLD) vs. comparison communities, we fit regression models with participation in POLD as the predictor. As secondary analyses, we fit models with POLD implementation level as the predictor (implementation levels were assessed via a survey of law enforcement agencies). We controlled for relevant community and agency characteristics. RESULTS: In the model with participation in POLD as a predictor, there was little difference in the rate of total alcohol-related crashes (rate ratio [RR] = 1.07, 95% CI: 0.85-1.34). In the model with level of implementation as a predictor, the rate of total alcohol-related crashes was comparable between communities with high implementation and those with no implementation (RR = 0.89; 95% CI: 0.71-1.10). Similar results were seen for alcohol-related crashes with nonfatal injury and property damage outcomes. CONCLUSIONS: This study found little evidence that the POLD initiative, as currently implemented, was associated with reductions in traffic crashes across communities in Minnesota. Further research could explore whether specific characteristics of POLD are particularly important and whether POLD could be combined with other strategies to reduce traffic crashes and other alcohol-related harms.

Alcohol-impaired driving enforcement priorities and strategies in a nationwide sample of U.S. law enforcement agencies.

OBJECTIVE: Excessive alcohol consumption leads to a range of public health problems and social and financial burdens. Traffic crashes resulting from alcohol-involved driving are a major contributor to the overall health consequences of alcohol. Various laws and enforcement strategies aim to prevent alcohol-involved driving. The extent to which law enforcement agencies prioritize enforcement of alcohol-impaired driving laws can help to reduce alcohol-impaired driving. Among law enforcement agencies in the US, we examined prioritization of alcohol-impaired driving enforcement and how it is associated with use of specific enforcement strategies, as well as agency and community characteristics. METHODS: We conducted a survey of a national sample of 1,024 US police and sheriff agencies in 2019. We assessed prioritization of alcohol-impaired driving enforcement, use of specific enforcement strategies (saturation patrols, sobriety checkpoints, open container law enforcement, training field officers to identify driving impairment), and agency and jurisdiction characteristics. We assessed how priority of enforcement (high vs. low) was associated with use of specific strategies, and agency and jurisdiction characteristics using regression models that accounted for agencies nesting within states. RESULTS: A majority of agencies (68%) placed a high priority on alcohol-impaired driving enforcement. Almost all agencies (93%) reported performing at least one alcohol-impaired driving enforcement strategy and the most common strategy used was saturation patrols. Agencies that prioritized alcohol-impaired driving enforcement were more likely to use sobriety checkpoints and saturation patrols, conduct enforcement of open container laws and train field officers in identifying driving impairment (p < 0.05). They were also more likely to have an officer assigned primarily to alcohol enforcement, have an alcohol division, and serve jurisdictions that had fewer Black residents (p < 0.05). CONCLUSIONS: Many law enforcement agencies utilize strategies to address alcohol-impaired driving, however, some strategies are underutilized and an opportunity exists for agencies to incorporate additional strategies to help prevent alcohol-impaired driving. Agencies that made alcohol-impaired driving enforcement a priority were more likely to conduct related enforcement strategies. Encouraging police and sheriff agencies to prioritize alcohol-impaired driving enforcement may be an effective approach for preventing alcohol-related harms.

Strategies Used by Local Law Enforcement Agencies to Prevent Overservice of Alcohol in the United States.

Overservice of alcohol, defined as commercial provision of alcohol to an individual who is obviously intoxicated, is illegal in most states and contributes to motor vehicle crashes and violence. Law enforcement agencies use various strategies that aim to reduce overservice at licensed alcohol establishments (e.g., bars, restaurants). Place of Last Drink (POLD) data collection is an emerging overservice enforcement strategy. POLD identifies patterns of overservice, which can provide support for targeted interventions to prevent overservice at offending establishments. We describe the prevalence of POLD and other overservice enforcement strategies and associations with agency characteristics, which has important implications for public health and safety. We conducted a national survey of 1024 municipal (e.g., town, city) and county law enforcement agencies in 2019 (response rate = 73%). We assessed the use of overservice enforcement strategies conducted by the agencies over the past year. We examined associations of each type of overservice enforcement strategy with agency and jurisdiction characteristics using regression models. 27% of responding agencies reported conducting overservice enforcement and 7% conducted POLD data collection specifically. Municipal (vs. county) agencies and agencies with an officer assigned primarily to alcohol enforcement activities were significantly more likely to conduct overservice enforcement generally but not POLD data collection specifically. Overservice enforcement in general, and POLD data collection specifically, are not widely conducted. Prevention of overservice has the potential to reduce harms related to excessive alcohol consumption. Increased evaluation of overservice enforcement strategies should be prioritized.

Core Decompression and Bone Marrow Aspiration Concentrate Grafting for Osteonecrosis of the Femoral Head.

BACKGROUND: Core decompression (CD) with bone marrow aspiration concentrate (BMAC) is a technique that may improve outcomes in osteonecrosis of the femoral head (ONFH). The primary aim of this study was to evaluate the radiographic progression free survival (PFS) of CD augmented with BMAC. Secondary aims were to determine the survivorship with conversion (CFS) to total hip arthroplasty (THA) as an endpoint, determine prognostic factors, and characterize the cellular quality of the BMAC. METHODS: A retrospective cohort study of 61 femoral heads (40 patients) was performed. Patient demographics, comorbidities, BMI, smoking status, etiology, location and extent of ONFH were recorded. The primary endpoint was radiographic progression of ONFH and secondarily, conversion to THA. Additional aims were to determine predictive factors for progression and report the cellular characteristics of the BMAC. Data obtained were compared to the results of a prior randomized controlled trial comparing CD alone versus CD with polymethylmethacrylate cement (PMMA) augmentation. RESULTS: Radiographic PFS of CD with BMAC at 2 and 5 years was 78.3% and 53.3%, respectively. The risk of progression was lower in the CD with BMAC group compared to CD alone (HR0.45, p = 0.03), however this difference no longer remained statistically significant on multivariate analysis. Conversion to total hip arthroplasty free survival (CFS) of CD with BMAC at both 2 and 5 years was 72.1% and 54.6%, respectively with no differences compared to the control groups (CD alone, CD and PMMA). The predictive factors for progression were obesity (BMI ≥ 30) and the extent of the disease as quantified by either percentage involvement, necrotic index or modified necrotic index. CONCLUSIONS: No differences in PFS or CFS between CD with BMAC compared to CD alone or CD with PMMA were identified. Independent statistically significant predictors of progression-free survival or conversion to THA are BMI ≥ 30 and the extent of ONFH. Further research with an adequately powered randomized controlled trial is needed. LEVEL OF EVIDENCE: 3.

Evaluation of Quality Improvement Methods for Altering Opioid Prescribing Behavior in Hand Surgery.

BACKGROUND: The opioid epidemic in the United States continues to be problematic as morbidity and mortality rates increase yearly. Orthopaedic surgeons are the third highest prescribing group among physicians. Studies show that orthopaedic surgeons tend to overprescribe opioids, but published data on patient opioid utilization, pain management satisfaction, and national clinical practice guidelines on opioid prescribing are scarce or lacking. Furthermore, little information is available on influences on physician prescribing behavior and whether changes in prescribing habits are lasting. METHODS: Using recently published opioid utilization and prescribing guidelines for hand surgery, we created an opioid prescribing quality improvement program with the aim of reducing postoperative opioid prescribing without negatively impacting patient pain satisfaction. The main aspect of the program was the implementation and modification of an opioid prescribing order set, but the program also included surgeon education-executed in 2 intervention steps-about how their prescribing behavior compared with that of their peers. Three phases of data representing 3 months each were collected prior to, between, and after the interventions. RESULTS: Two thousand and sixty-seven hand surgery cases were reviewed (629 in Phase 1, 655 in Phase 2, and 783 in Phase 3). The average number of morphine milligram equivalents (MMEs) was reduced from 142.0 in Phase 1 to 69.9 in Phase 2 (51% reduction) to 61.3 in Phase 3 (57% reduction compared with Phase 1). Significant reductions in MMEs occurred across the procedural categories as well as the hand surgeons. Patient pain satisfaction was similar before and after implementation of the first intervention (p = 0.96). CONCLUSIONS: Quality improvement methods were effective in altering prescribing behavior by physicians in the long term, and our approach may be effective if applied more widely. Similar studies on quality improvement methods and prescribing behavior, patient opioid utilization, and patient satisfaction with pain management are needed in other orthopaedic subspecialties. CLINICAL RELEVANCE: Evidence-based guidelines, a quality improvement process, and unblinded information on prescribing behavior compared with that of peers may result in long-lasting reductions in surgeons' opioid prescribing practices.

Compartment Syndrome: Evaluation of Skeletal Muscle Ischemia and Physiologic Biomarkers in Controlled Conditions Within Ex Vivo Isolated Muscle Bundles.

OBJECTIVES: To identify potential physiologic markers of muscle ischemia to serve as diagnostic indicators of compartment syndrome. We hypothesize that muscle bundles in hypoxic conditions will elicit decreases in potential hydrogen (pH) and increases in lactate and potassium that correlates with decreased muscle twitch forces. METHODS: We performed an ex vivo evaluation of individual skeletal muscle bundles obtained from a swine's diaphragm that were exposed to hypoxic conditions and compared with control groups. Over a 4-hour period, we evaluated the following parameters for each muscle bundle: muscle twitch forces and levels of potassium, lactate, and pH. Comparisons between the hypoxic and control groups were calculated at each time point using the 2-tailed Wilcoxon rank sum test for nonparametric data. Longitudinal associations between biomarkers and muscle twitch forces were tested using repeated measures analyses. RESULTS: The hypoxic group elicited more significant decreases in normalized muscle twitch forces than the control group at all time points (0.15 g vs. 0.55 g at 4 hours, P < 0.001). Repeated measures analyses of the hypoxic group demonstrated a statistically significant association between potassium, lactate, and normalized peak force over the course of time. Potassium demonstrated the strongest association with a 1 mmol/L unit increase in potassium associated with a 2.9 g decrease in normalized peak force (95% confidence interval -3.3 to -2.4, P < 0.001). The pH of all muscle baths increased over the course of time at similar rates between the study groups. CONCLUSIONS: This study used an ex vivo ischemic skeletal muscle model as a representation for pathophysiologic pathways associated with compartment syndrome. In this experimental approach we were unable to evaluate the pH of the muscle bundles due to continuous applied gassing. Our findings support further evaluations of potassium and lactate levels as potential diagnostic markers.

Nephrology care prior to end-stage renal disease and outcomes among new ESRD patients in the USA.

BACKGROUND: Longer nephrology care before end-stage renal disease (ESRD) has been linked with better outcomes. METHODS: We investigated whether longer pre-end-stage renal disease (ESRD) nephrology care was associated with lower mortality at both the patient and state levels among 443 761 incident ESRD patients identified in the USA between 2006 and 2010. RESULTS: Overall, 33% of new ESRD patients had received no prior nephrology care, while 28% had received care for >12 months. At the patient level, predictors of >12 months of nephrology care included having health insurance, white race, younger age, diabetes, hypertension and US region. Longer pre-ESRD nephrology care was associated with lower first-year mortality (adjusted hazard ratio = 0.58 for >12 months versus no care; 95% confidence interval 0.57-0.59), higher albumin and hemoglobin, choice of peritoneal dialysis and native fistula and discussion of transplantation options. Living in a state with a 10% higher proportion of patients receiving >12 months of pre-ESRD care was associated with a 9.3% lower relative mortality rate, standardized for case mix (R (2) = 0.47; P < 0.001). CONCLUSIONS: This study represents the largest cohort of incident ESRD patients to date. Although we did not follow patients before ESRD onset, our findings, both at the individual patient and state levels, reflect the importance of early nephrology care among those with chronic kidney disease.

Variation in infection prevention practices in dialysis facilities: results from the national opportunity to improve infection control in ESRD (End-Stage Renal Disease) project.

OBJECTIVE To observe patient care across hemodialysis facilities enrolled in the National Opportunity to Improve Infection Control in ESRD (end-stage renal disease) (NOTICE) project in order to evaluate adherence to evidence-based practices aimed at prevention of infection. SETTING AND PARTICIPANTS Thirty-four hemodialysis facilities were randomly selected from among 772 facilities in 4 end-stage renal disease participating networks. Facility selection was stratified on dialysis organization affiliation, size, socioeconomic status, and urban/rural status. MEASUREMENTS Trained infection control evaluators used an infection control worksheet to observe 73 distinct infection control practices at the hemodialysis facilities, from October 1, 2011, through January 31, 2012. RESULTS There was considerable variation in infection control practices across enrolled facilities. Overall adherence to recommended practices was 68% (range, 45%-92%) across all facilities. Overall adherence to expected hand hygiene practice was 72% (range, 10%-100%). Compliance to hand hygiene before and after procedures was high; however, during procedures hand hygiene compliance averaged 58%. Use of chlorhexidine as the specific agent for exit site care was 19% overall but varied from 0% to 35% by facility type. The 8 checklists varied in the frequency of perfect performance from 0% for meeting every item on the checklist for disinfection practices to 22% on the arteriovenous access practices at initiation. CONCLUSIONS Our findings suggest that there are many areas for improvement in hand hygiene and other infection prevention practices in end-stage renal disease. These NOTICE project findings will help inform the development of a larger quality improvement initiative at dialysis facilities.

TSG-6 released from intradermally injected mesenchymal stem cells accelerates wound healing and reduces tissue fibrosis in murine full-thickness skin wounds.

Proper activation of macrophages (Mφ) in the inflammatory phase of acute wound healing is essential for physiological tissue repair. However, there is a strong indication that robust Mφ inflammatory responses may be causal for the fibrotic response always accompanying adult wound healing. Using a complementary approach of in vitro and in vivo studies, we here addressed the question of whether mesenchymal stem cells (MSCs)-due to their anti-inflammatory properties-would control Mφ activation and tissue fibrosis in a murine model of full-thickness skin wounds. We have shown that the tumor necrosis factor-α (TNF-α)-stimulated protein 6 (TSG-6) released from MSCs in co-culture with activated Mφ or following injection into wound margins suppressed the release of TNF-α from activated Mφ and concomitantly induced a switch from a high to an anti-fibrotic low transforming growth factor-ß1 (TGF-ß1)/TGF-ß3 ratio. This study provides insight into what we believe to be a previously undescribed multifaceted role of MSC-released TSG-6 in wound healing. MSC-released TSG-6 was identified to improve wound healing by limiting Mφ activation, inflammation, and fibrosis. TSG-6 and MSC-based therapies may thus qualify as promising strategies to enhance tissue repair and to prevent excessive tissue fibrosis.