An identification and brief advice programme for low-risk alcohol consumption in an acute medical setting: an implementation study.

OBJECTIVES: To implement an identification and brief advice (IBA) intervention to detect low-risk/hazardous alcohol consumption. DESIGN: Implementation was guided through the use of quality improvement tools and training. SETTING: This study was conducted over an 18-month period from April 2010 to September 2011 on a 42-bed acute medical unit at a central London acute hospital. PARTICIPANTS: All medical patients over the age of 18 admitted to the acute assessment unit were eligible; any patient unable to provide a medical history either through language barriers or due to illness was excluded. MAIN OUTCOME MEASURES: Percentage of medical patients admitted each week to the acute assessment unit who were screened for low-risk/hazardous alcohol consumption. RESULTS: Weekly data were analysed in time series run charts and cross-referenced to the date of educational sessions and their effect on the uptake of screening monitored. A demonstrable change in the mean percentage number of patients screened was observed in different time periods, 67.3-80.1%, following targeted teaching on the AAU. CONCLUSIONS: Our study demonstrates the successful use of quality improvement methodology to guide the implementation of Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), an IBA intervention, in the acute medical setting. The incorporation of the AUDIT-C into an admission document has been well accepted by the junior doctors, attaining an average (mean) of 80% of patients being screened using the tool. Targeted teaching of clinical staff involved in admitting patients appears to be the most effective method in improving uptake of IBA by junior doctors

Improving GHB withdrawal with baclofen: study protocol for a feasibility study for a randomised controlled trial

Background: GHB (gamma-hydroxybutyrate) and its pro-drugs GBL (gamma-butyrolactone) and 1,4-butanediol (1,4-BD) are central nervous system depressants whose street names include ‘G’ and ‘liquid ecstasy’. They are used recreationally predominately for their stimulant and pro-sexual effects or for sedation to help with sleep and/or to ‘come down’ after using stimulant recreational drugs. Although overall population prevalence is low (0.1 %), in some groups such as men who have sex with men, GHB/GBL use may reach 20 %. GHB/GBL dependence may be associated with severe withdrawal with individuals presenting either acutely to emergency departments or to addiction services for support. Benzodiazepines are currently prescribed for GHB/GBL detoxification but do not prevent all complications, such as behavioural disinhibition, that may require hospitalisation or admission to a high dependency /intensive care unit. The GABAB receptor mediates most effects of GHB/GBL and the GABAB agonist, baclofen, has shown promise as an adjunct to benzodiazepines in reducing withdrawal severity when prescribed both during withdrawal and as a 2-day ‘preload’ prior to detoxification. The key aim of this feasibility study is provide information about recruitment and characteristics of the proposed outcome measure (symptom severity, complications including delirium and treatment escalation) to inform an application for a definitive randomised placebo controlled trial to determine the role of baclofen in the management of GHB/GBL withdrawal and whether starting baclofen 2 days earlier improves outcomes further. Methods/design: This is a prospective, randomised, double-blind, placebo-controlled feasibility study that will recruit participants (aged over 18 years) who are GHB/GBL- dependent and wish to undergo planned GHB/GBL detoxification or are at risk of acute withdrawal and are inpatients requiring unplanned withdrawal. We aim to recruit 88 participants: 28 unplanned inpatients and 60 planned outpatients. During detoxification we will compare baclofen 10 mg three times a day with placebo as an adjunct to the usual benzodiazepine regimen. In the planned outpatient arm, we will also compare a 2-day preload of baclofen 10 mg three times a day with placebo. Ratings of GHB/GBL withdrawal, sleep, depression, anxiety as well as GHB/GBL use will be collected. The main data analyses will be descriptive about recruitment and characterising the impact of adding baclofen to the usual benzodiazepine regimen on measures and outcomes of GHB/GBL withdrawal to provide estimates of variability and effect size. A qualitative approach will evaluate research participant and clinician acceptability and data collected to inform cost-effectiveness. Discussion: This feasibility study will inform a randomised controlled trial to establish whether adding baclofen to a benzodiazepine regimen reduces the severity and complications of GHB/GBL withdrawal

The Identification of Infrared Synchrotron Radiation from Cassiopeia A

We report the discovery of polarized flux at 2.2 micron from the bright shell of the approximately 320 year old supernova remnant Cas A. The fractional polarizations are comparable at 6 cm and 2.2 micron, and the polarization angles are similar, demonstrating that synchrotron radiation from the same relativistic plasma is being observed at these widely separated wavebands. The relativistic electrons radiating at 2.2 micron have an energy of ~ 150 GeV, (gamma ~ 3e5), assuming an ~500 microGauss magnetic field. The total intensity at 2.2 micron lies close to the power law extrapolation from radio frequencies, showing that relativistic particle acceleration is likely an ongoing process; the infrared emitting electrons were accelerated no longer than ~80 years ago. There is a small but significant concave curvature to the spectrum, as expected if the accelerating shocks have been modified by the back pressure of the cosmic rays; given calibration uncertainties, this conclusion must be considered tentative at present. The 2.2 micron polarization angles and the emission-line filaments observed by HST are both offset from the local radial direction by 10 - 20 degrees, providing evidence that the magnetic fields in Cas A are generated by Rayleigh-Taylor instabilities in the decelerating ejecta.Comment: 11 pages, 3 figures, accepted for publication Ap

Comparative Dosimetric Analysis and Normal Tissue Complication Probability Modelling of Four-Dimensional Computed Tomography Planning Scans Within the UK NeoSCOPE Trial

Aims: NeoSCOPE is a trial of two different neoadjuvant chemoradiotherapy regimens for resectable oesophageal cancer and was the first multicentre trial in the UK to incorporate four-dimensional computed tomography (4D-CT) into radiotherapy planning. Despite 4D-CT being increasingly accepted as a standard of care for lower third and junctional oesophageal tumours, there is limited evidence of its benefit over standard three-dimensional computed tomography (3D-CT). // Materials: Using NeoSCOPE 4D-CT cases, we undertook a dosimetric comparison study of 3D-CT versus 4D-CT plans comparing target volume coverage and dose to organs at risk. We used established normal tissue complication probability models to evaluate the potential toxicity reduction of using 4D-CT plans in oesophageal cancer. // Results: 4D-CT resulted in a smaller median absolute PTV volume and lower dose levels for all reported constraints with comparable target volume coverage. NTCP modelling suggests a significant relative risk reduction of cardiac and pulmonary toxicity endpoints with 4D-CT. // Conclusion: Our work shows that incorporating 4D-CT into treatment planning may significantly reduce the toxicity burden from this treatment

Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial

Background: Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy. Methods: In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493. Findings: Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12·1, 95% CI 3·7–39·9; p<0·0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14·0, 4·2–46·2; p<0·0001). These differences remained significant with sensitivity analyses. Interpretation: Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown

Demand for and availability of specialist chemsex services in the UK: A cross-sectional survey of sexual health clinics.

BACKGROUND/INTRODUCTION: Chemsex amongst men who have sex with men (MSM) is well documented in major cities within the United Kingdom (UK), but few data from less urban areas exist. We undertook a survey of sexual health clinic (SHC) healthcare workers (HCWs) to explore demand for and availability of chemsex services to understand training needs and inform service planning. METHODS: An online survey was distributed to HCWs in all SHCs across the UK. For English clinics, we explored associations between responses and geo-demographic region using national surveillance data and population statistics. RESULTS: Responses were received from 56% (150/270) of SHC's in the UK (89% (133/150) from English clinics). 80% (103/129) of UK clinics reported chemsex consultations and in 50% (65/129) these occurred at least monthly, with no significant difference found when analysed by the geo-demographic characteristics of England (p=0.38). Respondents from most clinics (99% (117/118)) wanted chemsex training, 81 %(103/129) felt there was a local clinical need for a chemsex service and 33% (14/43) had chemsex care-pathways for referrals in place. DISCUSSION/CONCLUSION: Patients reporting chemsex regularly present to SHCs throughout the UK including rural areas. Given the potential negative health outcomes associated with chemsex, there is a need for local, high quality, appropriate services and training to minimise harm

Second and third season QUaD CMB temperature and polarization power spectra

We report results from the second and third seasons of observation with the QUaD experiment. Angular power spectra of the Cosmic Microwave Background are derived for both temperature and polarization at both 100 GHz and 150 GHz, and as cross frequency spectra. All spectra are subjected to an extensive set of jackknife tests to probe for possible systematic contamination. For the implemented data cuts and processing technique such contamination is undetectable. We analyze the difference map formed between the 100 and 150 GHz bands and find no evidence of foreground contamination in polarization. The spectra are then combined to form a single set of results which are shown to be consistent with the prevailing LCDM model. The sensitivity of the polarization results is considerably better than that of any previous experiment -- for the first time multiple acoustic peaks are detected in the E-mode power spectrum at high significance.Comment: 24 pages, 23 figures, updated to reflect published versio

Scientific optimization of a ground-based CMB polarization experiment

We investigate the science goals achievable with the upcoming generation of ground-based Cosmic Microwave Background polarization experiments and calculate the optimal sky coverage for such an experiment including the effects of foregrounds. We find that with current technology an E-mode measurement will be sample-limited, while a B-mode measurement will be detector-noise-limited. We conclude that a 300 sq deg survey is an optimal compromise for a two-year experiment to measure both E and B-modes, and that ground-based polarization experiments can make an important contribution to B-mode surveys. Focusing on one particular experiment, QUaD, a proposed bolometric polarimeter operating from the South Pole, we find that a ground-based experiment can make a high significance measurement of the acoustic peaks in the E-mode spectrum, and will be able to detect the gravitational lensing signal in the B-mode spectrum. Such an experiment could also directly detect the gravitational wave component of the B-mode spectrum if the amplitude of the signal is close to current upper limits. We also investigate how a ground-based experiment can improve constraints on the cosmological parameters. We estimate that by combining two years of QUaD data with the four-year WMAP data, an optimized ground-based polarization experiment can improve constraints on cosmological parameters by a factor of two. If the foreground contamination can be reduced, the measurement of the tensor-to-scalar ratio can be improved by up to a factor of six over that obtainable from WMAP alone.Comment: 17 pages, 11 figures replaced with version accepted by MNRA