(Mis)understanding alcohol use disorder: Making the case for a public health first approach

‘Alcohol use disorder’ (AUD) is used by several contemporary conceptualizations to identify, treat and prevent problems associated with alcohol use. Such conceptualizations encompass diagnostic classifications and broader frameworks for policy and practice. However, current AUD concepts are subject to multiple tensions and limitations in capturing and responding to the complex and heterogeneous nature of alcohol problems. Further, public understandings of alcohol problems are heavily divergent from professional AUD concepts and remain embedded within an ‘alcoholism’ master narrative in which disease model stereotypes come with multiple costs for prevention and ‘recovery’. The persistence of a problematic ‘alcoholism’ paradigm reflects the coalescing of multiple forces including the cognitive appeal of reductionism, motives to stigmatize and ‘other’, and an over-emphasis on AUD as an individually located biomedical problem. Public misperceptions of AUD as a matter of the individual, the individual’s essence, and misconceived notions of responsibility and control have been bolstered by industry interests and the ascension of neuroscience and genetics, in turn diverting attention from the importance of the environmental and commercial determinants of health and the effectiveness of under-utilized public health policies. We call for multiple stakeholders to support efforts to prioritize a public health first approach to advancing AUD research, policy and treatment in order to make significant advances in AUD prevention and treatment. We offer several recommendations to assist in shifting public understanding and scientific limitations in AUD concepts and responses

Balancing the bio in a biopsychosocial model of hazardous drinking and alcohol use disorders

How alcohol problems are represented, including as ‘Alcohol Use Disorder’ (AUD), has a broad set of implications for research, policy and practice. A biopsychosocial approach is commonly offered as a means of taking into account the various environmental and individual level factors that may contribute to so called mental and behavioural disorders including AUD. In this reply we argue that the reference article presents a heavy focus on ‘bio’ factors without sufficiently acknowledging the potential costs of doing so, particularly that a focus on individual level ‘bio’ factors may undermine the utilization of effective environmental policy levers whilst potentially harming AUD recovery processes. Thus, we call for a more balanced focus on the ‘psychosocial’ factors related to AUD

The effect of dietary calcium inclusion on broiler gastrointestinal pH: quantification and method optimization

There is little consensus as to the most appropriate methodology for the measurement of gastrointestinal pH in chickens. An experiment was conducted to establish the optimum sampling method for the determination of broiler digesta pH in birds fed differing levels of dietary calcium. Ross 308 broilers (n = 60) were fed one of two experimental diets, one containing 0.8% monocalcium phosphate and 2% limestone and one containing 0.4% monocalcium phosphate and 1% limestone. Four factors were investigated to determine the most appropriate method of measuring broiler gastrointestinal digesta pH: removal from the tract, prolonged air exposure, altering the temperature of the assay, and controlling the water content of the digesta. The conditions were assessed at bird ages from 7 to 42 d post hatch. Dietary Ca content had no significant effect on in situ pH, but it contributed towards variance in ex situ pH of both gizzard and duodenum digesta

Fast coarsening in unstable epitaxy with desorption

Homoepitaxial growth is unstable towards the formation of pyramidal mounds when interlayer transport is reduced due to activation barriers to hopping at step edges. Simulations of a lattice model and a continuum equation show that a small amount of desorption dramatically speeds up the coarsening of the mound array, leading to coarsening exponents between 1/3 and 1/2. The underlying mechanism is the faster growth of larger mounds due to their lower evaporation rate.Comment: 4 pages, 4 PostScript figure

Learning from COVID-19 related trial adaptations to inform efficient trial design—a sequential mixed methods study

Background Many clinical trial procedures were often undertaken in-person prior to the COVID-19 pandemic, which has resulted in adaptations to these procedures to enable trials to continue. The aim of this study was to understand whether the adaptations made to clinical trials by UK Clinical Trials Units (CTUs) during the pandemic have the potential to improve the efficiency of trials post-pandemic. Methods This was a mixed methods study, initially involving an online survey administered to all registered UK CTUs to identify studies that had made adaptations due to the pandemic. Representatives from selected studies were qualitatively interviewed to explore the adaptations made and their potential to improve the efficiency of future trials. A literature review was undertaken to locate published evidence concerning the investigated adaptations. The findings from the interviews were reviewed by a group of CTU and patient representatives within a workshop, where discussions focused on the potential of the adaptations to improve the efficiency of future trials. Results Forty studies were identified by the survey. Fourteen studies were selected and fifteen CTU staff were interviewed about the adaptations. The workshop included 15 CTU and 3 patient representatives. Adaptations were not seen as leading to direct efficiency savings for CTUs. However, three adaptations may have the potential to directly improve efficiencies for trial sites and participants beyond the pandemic: a split remote-first eligibility assessment, recruitment outside the NHS via a charity, and remote consent. There was a lack of published evidence to support the former two adaptations, however, remote consent is widely supported in the literature. Other identified adaptations may benefit by improving flexibility for the participant. Barriers to using these adaptations include the impact on scientific validity, limitations in the role of the CTU, and participant’s access to technology. Conclusions Three adaptations (a split remote-first eligibility assessment, recruitment outside the NHS via a charity, and remote consent) have the potential to improve clinical trials but only one (remote consent) is supported by evidence. These adaptations could be tested in future co-ordinated ‘studies within a trial’ (SWAT)

Optimal designs for rational function regression

We consider optimal non-sequential designs for a large class of (linear and nonlinear) regression models involving polynomials and rational functions with heteroscedastic noise also given by a polynomial or rational weight function. The proposed method treats D-, E-, A-, and $\Phi_p$-optimal designs in a unified manner, and generates a polynomial whose zeros are the support points of the optimal approximate design, generalizing a number of previously known results of the same flavor. The method is based on a mathematical optimization model that can incorporate various criteria of optimality and can be solved efficiently by well established numerical optimization methods. In contrast to previous optimization-based methods proposed for similar design problems, it also has theoretical guarantee of its algorithmic efficiency; in fact, the running times of all numerical examples considered in the paper are negligible. The stability of the method is demonstrated in an example involving high degree polynomials. After discussing linear models, applications for finding locally optimal designs for nonlinear regression models involving rational functions are presented, then extensions to robust regression designs, and trigonometric regression are shown. As a corollary, an upper bound on the size of the support set of the minimally-supported optimal designs is also found. The method is of considerable practical importance, with the potential for instance to impact design software development. Further study of the optimality conditions of the main optimization model might also yield new theoretical insights.Comment: 25 pages. Previous version updated with more details in the theory and additional example

An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial

Objective: To evaluate the clinical efficacy of an established programme of occupational therapy in maintaining functional activity and reducing further health risks from inactivity in care home residents living with stroke sequelae.Design: Pragmatic, parallel group, cluster randomised controlled trial.Setting: 228 care homes (>10 beds each), both with and without the provision of nursing care, local to 11 trial administrative centres across the United Kingdom.Participants: 1042 care home residents with a history of stroke or transient ischaemic attack, including those with language and cognitive impairments, not receiving end of life care. 114 homes (n=568 residents, 64% from homes providing nursing care) were allocated to the intervention arm and 114 homes (n=474 residents, 65% from homes providing nursing care) to standard care (control arm). Participating care homes were randomised between May 2010 and March 2012.Intervention: Targeted three month programme of occupational therapy, delivered by qualified occupational therapists and assistants, involving patient centred goal setting, education of care home staff, and adaptations to the environment.Main outcome measures: Primary outcome at the participant level: scores on the Barthel index of activities of daily living at three months post-randomisation. Secondary outcome measures at the participant level: Barthel index scores at six and 12 months post-randomisation, and scores on the Rivermead mobility index, geriatric depression scale-15, and EuroQol EQ-5D-3L questionnaire, at all time points.Results: 64% of the participants were women and 93% were white, with a mean age of 82.9 years. Baseline characteristics were similar between groups for all measures, personal characteristics, and diagnostic tests. Overall, 2538 occupational therapy visits were made to 498 participants in the intervention arm (mean 5.1 visits per participant). No adverse events attributable to the intervention were recorded. 162 (11%) died before the primary outcome time point, and 313 (30%) died over the 12 months of the trial. The primary outcome measure did not differ significantly between the treatment arms. The adjusted mean difference in Barthel index score at three months was 0.19 points higher in the intervention arm (95% confidence interval −0.33 to 0.70, P=0.48). Secondary outcome measures also showed no significant differences at all time points.Conclusions: This large phase III study provided no evidence of benefit for the provision of a routine occupational therapy service, including staff training, for care home residents living with stroke related disabilities. The established three month individualised course of occupational therapy targeting stroke related disabilities did not have an impact on measures of functional activity, mobility, mood, or health related quality of life, at all observational time points. Providing and targeting ameliorative care in this clinically complex population requires alternative strategies