Head shops and new psychoactive substances: a public health perspective.

In 2010, Ireland found itself at the eye of an international storm as a network of head shops emerged selling new psychoactive substances (NPS) and Irish youth rapidly became the heaviest users of NPS in Europe. Within months, the Irish government enacted novel legislation, which has since been copied by other countries, which effectively stopped the head shops selling NPS. Critics of this policy argued that it could cause harms to escalate. A number of separate studies indicate that a range of drug-related harms increased amongst Irish youth during the period of head shop expansion. Within months of their closure, health harms began to decline. NPS-related addiction treatment episodes reduced and admissions to both psychiatric and general hospitals related to any drug problem began to fall. Population use underwent sustained decline. Consequently, the closure of head shops can be viewed as a success in terms of public health.

Improvement in psychological wellbeing among adolescents with a substance use disorder attending an outpatient treatment programme.

OBJECTIVES: Adolescents with substance use disorders (SUDs) exhibit high rates of comorbid psychological problems. This study aimed to examine the impact of an outpatient substance use treatment programme upon the psychological wellbeing of adolescents. METHODS: A prospective study was carried out examining psychological symptoms in a group of adolescents attending the Youth Drug and Alcohol (YoDA) Addiction Service in Dublin. Participants were treated with evidenced based psychological models such as cognitive behavioural therapy, motivational interviewing and systemic family therapy. The Becks Youth Inventory was utilised to assess psychological symptoms at treatment entry and repeated three months later at follow up. RESULTS: Among 36 adolescents who were included in this study, poly-substance misuse was the norm. Almost three-quarter had a cannabis use disorder (CUD). There were significant reductions in mean subscale scores of depression (56.0 to 50.8, p = 0.003), anger (55.2 to 49.5, p < 0.001) and disruptive behaviour (61.6 to 56.5, p = 0.002) at follow up. Although there wasn't a statistically significant reduction in mean scores for anxiety, we observed a significant proportion of participants (p = 0.008) improving and moving out of a moderate to severe symptom range when examined by category. This was also the case for self-concept (p = 0.04). Furthermore this study revealed a positive correlation between the reduction in days of cannabis use and reduction in depressive scores (Pearson correlation 0.49, p = 0.01) among those with a CUD. CONCLUSION: The findings indicate that substance use treatment for adolescents is associated with important psychological and behavioural improvements.

Cannabis use and Associated Health Problems ­ What's the Harm?

Aim Cannabis is the most widely used illegal drug in Ireland. We sought to describe the changing pattern of cannabis use and cannabis related health harms. Methods Data was collated from two national population surveys and three national treatment databases, focusing on people under 34 years. Results Past month cannabis use among adolescents and young adults increased after 2011, coinciding with a decline in perceived risk of regular use. The prevalence estimate for cannabis dependence increased from 1.1% to 3.6% from 2011 to 2015. From 2008 to 2016, there were increases in the rates of cannabis related addiction treatment episodes among adolescents and among young adults of 40% and 168% respectively. Cannabis related admissions to general and psychiatric hospitals increased by 90% and 185% respectively. Conclusion A concerted public health response is required to address escalating cannabis related health harms which have coincided with the arrival of more potent cannabis.

The epidemiology and management of candidemia in Northern Ireland during 2002-2011, including a 12-month enhanced case review.

In Northern Ireland there are concerns about candidaemia, with rates higher than those reported in England and Wales. Our aim was to explore the epidemiology of candidaemia during a 10 year period and the clinical management upon suspicion of cases during a one year enhanced investigation in Northern Ireland.Candidaemia reports to the Public Health Agency were validated during 2002-2011 and used to examine incidence and antifungal sensitivity trends (during 2007-2011). A clinical proforma was used to collate information for all patients with candidaemia in 2011.The majority (96%) of isolates were captured through voluntary laboratory reporting. There was a year-on-year increase in candidaemia from 2002-2011, from 80 to 131 episodes (incidence rate ratio 1.09 95% CI 1.05-1.13). Rates were highest in males under 1 year and over 75 years. 83/98 (85%) of case notes were available from candidaemia patients during 2011. The most prevalent risk factors were patients on total parenteral nutrition (26 people, 31.3%), surgery in the two months prior to the candidaemia (25 people, 30.1%), significant steroid use in the previous 3 months (24 people, 28.9%) and active neoplastic disease (23 people, 27.7%),This study confirmed an increase in candidaemia rates over time, with the observed incidence in 2011 higher than England and Wales. We identified areas for improvement around the clinical management of candidaemia. We recommend raising the awareness of guidelines for fundoscopy, echocardiography and central venous catheter removal.

Severe hypocalcaemia and hypophosphataemia following intravenous iron and denosumab: a novel drug interaction.

We present the case of a 59-year-old woman with chronic kidney disease who suffered severe hypocalcaemia and hypophosphataemia after receiving denosumab and intravenous iron. This potentially life-threatening adverse drug interaction has never been reported before. We propose a mechanism to explain it with reference to the physiological derangements caused by both agents on calcium and phosphate homeostasis.

Opportunistic screening for atrial fibrillation in a rural area.

INTRODUCTION: Opportunistic screening is an effective means of identifying subjects with Atrial Fibrillation (AF). Previous studies of opportunistic screening have been performed areas with high population density and before the development of novel oral anticoagulant drugs. We performed a study to determine feasibility of AF screening in a predominantly rural, low population density area. METHODS: Over 6 months, subjects 65 years and older were screened by local General Practitioners using radial pulse palpation confirmed by 12 lead Electrocardiogram. Data were recorded electronically and those with newly identified AF were followed up to examine management post diagnosis. RESULTS: In total, 7262 subjects were screened and an irregular pulse was found in 916 (12.6%) of whom 735 (10.1%) had known AF and 55 (0.76%) had newly detected AF. Of these 55 patients with newly documented AF, 28 (50.9%) were women, 38 (69.1%) had hypertension and eight (14.5%) had a smoking history. Mean body mass index in subjects with newly documented AF was 28.9 kg/m(2)(SD 5.6) There was no significant difference in gender mix (P = 0.4), smoking history (P = 0.8) or alcohol history (P = 0.8) with the overall population. Fifty-one (92.7%) subjects had a CHA2DS2VaSC score ≥ 2 of whom 33 (64.7%) were eventually anticoagulated and nine (17.6%) commenced on Aspirin. The rate of newly identified patients in AF was lower than in previous reported key studies because of a higher rate of subjects with known AF. CONCLUSION: Opportunistic AF screening in a rural environment identified a substantial number of new cases, although less than in previous screening studies.

Cocaine use in Young Adults: Correlation with Early Onset Cannabis, Alcohol and Tobacco Use.

There is ongoing debate regarding the relationship between early tobacco, alcohol and cannabis use and later cocaine abuse. We utilised data from two Irish national general population surveys. Of the 1,897 young adult participants, the prevalence of lifetime use was as follows: tobacco 62%, alcohol 96%, cannabis 31% and cocaine 7.0%. Logistic regression analysis indicated that being single, earlier age of first alcohol use, and history of cannabis use were significant independent predictors of lifetime use of cocaine. The substance use route to cocaine use in this Irish sample is quite typical of that seen internationally. Those who commence alcohol use in the early teenage years are more likely to use cocaine subsequently, even after controlling for early onset cannabis use and other socio-demographic characteristics. This suggests that policies which delay age of first drinking may possibly also curtail cocaine use.

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.

Young people in drug treatment in Ireland: their views on substance use aetiology, trajectory, parents' role in substance use and coping skills.

OBJECTIVES: The aim of the current study was to gain insight into the process of initiation and progression to problematic use among young people who reach clinically significant levels of substance use requiring treatment. METHOD: Twenty young people, aged between 15 and 19 years from two different drug treatment centres in Ireland were interviewed regarding their views on their pathway into substance use, their progress to more problematic use, their perception of their parents' role, if any, in their trajectory and their typical coping style before treatment. Content analysis was conducted on the resulting narratives. RESULTS: The use of substances to cope with life stressors emerged as a prominent theme at initial and problematic stages of use. Multiple maladaptive coping approaches were reported. Both direct and indirect influences from parents in their substance use problem were cited. However, some participants reported that parents had no causal role in their substance use trajectory, in particular regarding mothers. CONCLUSIONS: The current findings suggest that substance misuse is a multi-determined problem and a number of intervention strategies are suggested to delay onset and related harms associated with adolescent substance use.

How social context impacts on the development, identification and treatment of mental and substance use disorders among young people - a qualitative study of health care workers.

Introduction Social context has a major influence on the detection and treatment of youth mental and substance use disorders in socioeconomically disadvantaged urban areas, particularly where gang culture, community violence, normalisation of drug use and repetitive maladaptive family structures prevail. This paper aims to examine how social context influences the development, identification and treatment of youth mental and substance use disorders in socioeconomically disadvantaged urban areas from the perspectives of health care workers. METHOD: Semi-structured interviews were conducted with health care workers (n=37) from clinical settings including: primary care, secondary care and community agencies and analysed thematically using Bronfenbrenner's Ecological Theory to guide analysis. RESULTS: Health care workers' engagement with young people was influenced by the multilevel ecological systems within the individual's social context which included: the young person's immediate environment/'microsystem' (e.g., family relationships), personal relationships in the 'mesosystem' (e.g., peer and school relationships), external factors in the young person's local area context/'exosystem' (e.g., drug culture and criminality) and wider societal aspects in the 'macrosystem' (e.g., mental health policy, health care inequalities and stigma). CONCLUSIONS: In socioeconomically disadvantaged urban areas, social context, specifically the micro-, meso-, exo-, and macro-system impact both on the young person's experience of mental health or substance use problems and services, which endeavour to address these problems. Interventions that effectively identify and treat these problems should reflect the additional challenges posed by such settings.

Harmonizing influenza primary-care surveillance in the United Kingdom: piloting two methods to assess the timing and intensity of the seasonal epidemic across several general practice-based surveillance schemes.

General Practitioner consultation rates for influenza-like illness (ILI) are monitored through several geographically distinct schemes in the UK, providing early warning to government and health services of community circulation and intensity of activity each winter. Following on from the 2009 pandemic, there has been a harmonization initiative to allow comparison across the distinct existing surveillance schemes each season. The moving epidemic method (MEM), proposed by the European Centre for Disease Prevention and Control for standardizing reporting of ILI rates, was piloted in 2011/12 and 2012/13 along with the previously proposed UK method of empirical percentiles. The MEM resulted in thresholds that were lower than traditional thresholds but more appropriate as indicators of the start of influenza virus circulation. The intensity of the influenza season assessed with the MEM was similar to that reported through the percentile approach. The MEM pre-epidemic threshold has now been adopted for reporting by each country of the UK. Further work will continue to assess intensity of activity and apply standardized methods to other influenza-related data sources.

Youth mental health in deprived urban areas: a Delphi study on the role of the GP in early intervention.

BACKGROUND: GPs, as healthcare professionals with whom young people commonly interact, have a central role in early intervention for mental health problems. However, successfully fulfilling this role is a challenge, and this is especially in deprived urban areas. AIMS: To inform a complex intervention to support GPs in this important role, we aim to identify the key areas in which general practice can help address youth mental health and strategies to enhance implementation. METHODS: We conducted a modified Delphi study which involved establishing an expert panel involving key stakeholders/service providers at two deprived urban areas. The group reviewed emerging literature on the topic at a series of meetings and consensus was facilitated by iterative surveys. RESULTS: We identified 20 individual roles in which GPs could help address youth mental health, across five domains: (1) prevention, health promotion and access, (2) assessment and identification, (3) treatment strategies, (4) interaction with other agencies/referral, and (5) ongoing support. With regard to strategies to enhance implementation, we identified a further 19 interventions, across five domains: (1) training, (2) consultation improvements, (3) service-level changes, (4) collaboration, and (5) healthcare-system changes. CONCLUSIONS: GPs have a key role in addressing youth mental health and this study highlights the key domains of this role and the key components of a complex intervention to support this role.

Effectiveness of trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2012/13 end of season results.

The effectiveness of the 2012/13 trivalent seasonal influenza vaccine (TIV) was assessed using a test-negative case-control study of patients consulting primary care with influenza-like illness in the United Kingdom. Strain characterisation was undertaken on selected isolates. Vaccine effectiveness (VE) against confirmed influenza A(H3N2), A(H1N1) and B virus infection, adjusted for age, sex, surveillance scheme (i.e. setting) and month of sample collection was 26% (95% confidence interval (CI): -4 to 48), 73% (95% CI: 37 to 89) and 51% (95% CI: 34 to 63) respectively. There was an indication, although not significant, that VE declined by time since vaccination for influenza A(H3N2) (VE 50% within three months, 2% after three months, p=0.25). For influenza A(H3N2) this is the second season of low VE, contributing to the World Health Organization (WHO) recommendation that the 2013/14 influenza vaccine strain composition be changed to an A(H3N2) virus antigenically like cell-propagated prototype 2012/13 vaccine strain (A/Victoria/361/2011). The lower VE seen for type B is consistent with antigenic drift away from the 2012/13 vaccine strain. The majority of influenza B viruses analysed belong to the genetic clade 2 and were antigenically distinguishable from the 2012/13 vaccine virus B/Wisconsin/1/2010 clade 3. These findings supported the change to the WHO recommended influenza B vaccine component for 2013/14.

The health burden of orphan zoonotic disease in the United Kingdom, 2005-2009.

'Orphan' zoonotic diseases attract disproportionately low scientific and public health attention for the impact that they can have. This article pulls together information on their health burden in the UK from routine and enhanced data sources. These diseases are heterogeneous in nature; some have very low case numbers (e.g. hydatid disease), whilst others affect hundreds of patients each year (e.g. toxoplasmosis). The number of deaths attributed to orphan zoonoses is relatively low, and the majority recorded in this article were caused by toxoplasmosis. There is a clear issue of under-reporting and under-diagnosis in the data sets presented, and further work should be carried out to obtain more accurate estimates of the prevalence of zoonotic infections. Joint human and veterinary studies are especially important for these diseases.

Response inhibition and elevated parietal-cerebellar correlations in chronic adolescent cannabis users.

The ability to successfully inhibit an inappropriate behaviour is a crucial component of executive functioning and its impairment has been linked to substance dependence. Cannabis is the most widely used illicit drug in adolescence and, given the accelerated neuromaturation during adolescence, it is important to determine the effects of cannabis use on neurocognitive functioning during this developmental period. In this study, a cohort of adolescent heavy cannabis users and age-matched non-cannabis-using controls completed a Go/No-Go paradigm. Users were impaired in performance on the task but voxelwise and region-of-interest comparisons revealed no activation differences between groups. Instead, an analysis of correlation patterns between task-activated areas revealed heightened correlation scores in the users between bilateral inferior parietal lobules and the left cerebellum. The increased correlation activity between these regions was replicated with resting state fMRI data and was positively correlated with self-reported, recent cannabis usage. The results suggests that the poorer inhibitory control of adolescent cannabis users might be related to aberrant connectivity between nodes of the response inhibition circuit and that this effect is observable in both task-induced and intrinsic correlation patterns. This article is part of the Special Issue Section entitled 'Neuroimaging in Neuropharmacology'.

Effectiveness of seasonal 2012/13 vaccine in preventing laboratory-confirmed influenza infection in primary care in the United Kingdom: mid-season analysis 2012/13.

The early experience of the United Kingdom (UK) is that influenza B has dominated the influenza 2012/13 season. Overall trivalent influenza vaccine (TIV) adjusted vaccine effectiveness (VE) against all laboratory-confirmed influenza in primary care was 51% (95% confidence interval (CI): 27% to 68%); TIV adjusted VE against influenza A alone or influenza B alone was 49% (95% CI: -2% to 75%) and 52% (95% CI: 23% to 70%) respectively. Vaccination remains the best protection against influenza.

Vaccine effectiveness of 2011/12 trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: evidence of waning intra-seasonal protection.

The 2011/12 season was characterised by unusually late influenza A (H3N2) activity in the United Kingdom (UK). We measured vaccine effectiveness (VE) of the 2011/12 trivalent seasonal influenza vaccine (TIV) in a test-negative case­control study in primary care. Overall VE against confirmed influenza A (H3N2) infection, adjusted for age, surveillance scheme and month, was 23% (95% confidence interval (CI): -10 to 47). Stratified analysis by time period gave an adjusted VE of 43% (95% CI: -34 to 75) for October 2011 to January 2012 and 17% (95% CI: -24 to 45) for February 2012 to April 2012. Stratified analysis by time since vaccination gave an adjusted VE of 53% (95% CI: 0 to 78) for those vaccinated less than three months, and 12% (95% CI: -31 to 41) for those vaccinated three months or more before onset of symptoms (test for trend: p=0.02). For confirmed influenza B infection, adjusted VE was 92% (95% CI: 38 to 99). A proportion (20.6%) of UK influenza A(H3N2) viruses circulating in 2011/12 showed reduced reactivity (fourfold difference in haemagglutination inhibition assays) to the A/Perth/16/2009 2011/12 vaccine component, with no significant change in proportion over the season. Overall TIV protection against influenza A(H3N2) infection was low, with significant intraseasonal waning.

Age-specific vaccine effectiveness of seasonal 2010/2011 and pandemic influenza A(H1N1) 2009 vaccines in preventing influenza in the United Kingdom.

An analysis was undertaken to measure age-specific vaccine effectiveness (VE) of 2010/11 trivalent seasonal influenza vaccine (TIV) and monovalent 2009 pandemic influenza vaccine (PIV) administered in 2009/2010. The test-negative case-control study design was employed based on patients consulting primary care. Overall TIV effectiveness, adjusted for age and month, against confirmed influenza A(H1N1)pdm 2009 infection was 56% (95% CI 42-66); age-specific adjusted VE was 87% (95% CI 45-97) in <5-year-olds and 84% (95% CI 27-97) in 5- to 14-year-olds. Adjusted VE for PIV was only 28% (95% CI -6 to 51) overall and 72% (95% CI 15-91) in <5-year-olds. For confirmed influenza B infection, TIV effectiveness was 57% (95% CI 42-68) and in 5- to 14-year-olds 75% (95% CI 32-91). TIV provided moderate protection against the main circulating strains in 2010/2011, with higher protection in children. PIV administered during the previous season provided residual protection after 1 year, particularly in the <5 years age group.

Morbidity and mortality associated with Clostridium difficile ribotype 078: a case-case study.

The morbidity and mortality associated with Clostridium difficile ribotype 078 were examined by comparison with other known outbreak strains. A healthcare interaction within eight weeks of a positive specimen significantly increased the likelihood of ribotype 078 compared with ribotype 027. Individuals with ribotype 078 also tended to come from community sources, have a hospital stay post specimen similar to ribotype 027 and a lower 30-day mortality, but these differences were not statistically significant. This study generates several hypotheses and a methodological platform to explore this unique profile.