A structured telephone-delivered intervention to reduce problem alcohol use (Ready2Change): study protocol for a parallel group randomised controlled trial

Background: Current population surveys suggest around 20% of Australians meet diagnostic criteria for an alcohol use disorder. However, only a minority seek professional help due to individual and structural barriers, such as low health literacy, stigma, geography, service operating hours and wait lists. Telephone-delivered interventions are readily accessible and ideally placed to overcome these barriers. We will conduct a randomised controlled trial (RCT) to examine the efficacy of a standalone, structured telephone-delivered intervention to reduce alcohol consumption, problem severity and related psychological distress among individuals with problem alcohol use. Methods/design: This is a single site, parallel group, two-arm superiority RCT. We will recruit 344 participants from across Australia with problem alcohol use. After completing a baseline assessment, participants will be randomly allocated to receive either the Ready2Change (R2C) intervention (n = 172, four to six sessions of structured telephone-delivered intervention, R2C self-help resource, guidelines for alcohol consumption and stress management pamphlets) or the control condition (n = 172, four phone check-ins < 5 min, guidelines for alcohol consumption and stress management pamphlets). Telephone follow-up assessments will occur at 4-6 weeks, 3 months, 6 months and 12 months post-baseline. The primary outcome is the Alcohol Use Disorders Identification Test (AUDIT) score administered at 3 months post-baseline. Secondary outcomes include change in AUDIT score (6 and 12 months post-baseline), change in number of past-month heavy drinking days, psychological distress, health and wellbeing, quality of life, client treatment evaluation and cost effectiveness. Discussion: This study will be one of the first RCTs conducted internationally to examine the impact of a standalone, structured telephone-delivered intervention to address problem alcohol use and associated psychological morbidity. The proposed intervention is expected to contribute to the health and wellbeing of individuals who are otherwise unlikely to seek treatment through mainstream service models, to reduce the burden on specialist services and primary care providers and to provide an accessible and proportionate response, with resulting cost savings for the health system and broader community. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000828224. Pre-registered on 16 May 2018

Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions

Introduction: Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality.Methods: This was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults.Results: We included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%.Conclusion: The majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.

Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions

Introduction: Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality.Methods: This was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults.Results: We included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%.Conclusion: The majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.

Convict ancestry: a neglected aspect of Australian identity

Claiming descent from convicts who were sent to Australia during the early period of British settlement is more than just about blood ties, it is also an aspect of national identity for many Australians. Analyses of nationally representative survey data show that younger, left-leaning, working class Australians are most likely to identify as convict descendants, while older, high income, educated, city dwellers are least likely to identify. Our findings also suggest that the 'hated stain' of convict ancestry is senescent, and will diminish with intergenerational replacement. Yet claims to convict descent remain divided along status lines. Interest in convicts and claims of convict heritage may comprise an element of 'popular taste', but as a consequence of this popularity, 'convict chic' is rejected by educated elites. Embraced by 'middle Australia', but shunned by cosmopolitan elites, convict ancestry is a neglected aspect of Australian identity. Whether claims of convict ancestry are 'real' or 'imaginary', the power of foundation myths to provide shared memories is evident in the salience of convict connections in Australia

Heteromeric Solute Carriers: Function, Structure, Pathology and Pharmacology

Solute carriers form one of three major superfamilies of membrane transporters in humans, and include uniporters, exchangers and symporters. Following several decades of molecular characterisation, multiple solute carriers that form obligatory heteromers with unrelated subunits are emerging as a distinctive principle of membrane transporter assembly. Here we comprehensively review experimentally established heteromeric solute carriers: SLC3-SLC7 amino acid exchangers, SLC16 monocarboxylate/H+ symporters and basigin/embigin, SLC4A1 (AE1) and glycophorin A exchanger, SLC51 heteromer Ost α-Ost β uniporter, and SLC6 heteromeric symporters. The review covers the history of the heteromer discovery, transporter physiology, structure, disease associations and pharmacology - all with a focus on the heteromeric assembly. The cellular locations, requirements for complex formation, and the functional role of dimerization are extensively detailed, including analysis of the first complete heteromer structures, the SLC7-SLC3 family transporters LAT1-4F2hc, b0,+AT-rBAT and the SLC6 family heteromer B0AT1-ACE2. We present a systematic analysis of the structural and functional aspects of heteromeric solute carriers and conclude with common principles of their functional roles and structural architecture