Estimating the measurable impact of local alcohol licensing policies on population health in England using ecological longitudinal data

BackgroundAlcohol policy in England is determined at local government level, and as a result differences between local authorities in priorities around how best to reduce the effects of alcohol consumption have led to variability in local composition of alcohol control policies and interventions. An important policy area is that of regulating the physical availability of alcohol and modifying the commercial drinking environment. We evaluated whether the intensity with which local licensing policies, including specifically cumulative impact zones, were implemented and enforced has resulted in measurable differences in local population health.MethodsAlcohol and late night refreshment licensing data (2007–12) from the Home Office were linked to alcohol-related hospital admissions from the Local Alcohol Profiles for England, and to population size and area deprivation at local area level. Cumulative policy and enforcement intensity was coded as passive, medium, or high on the basis of presence of cumulative impact zones, whether any new licence applications were successfully challenged, or both. Changes in directly age-standardised rates of people admitted to hospital with alcohol-related conditions in 2009 to quarter one of 2015 were analysed with mixed-effects log-rate models adjusted for seasonality, population size, deprivation, and alcohol-related crime rate.FindingsData were obtained for all 326 lower tier local authority areas in England, of which 319 provided licensing activity data. Spatial autocorrelation in licensing policy intensity was negligible (Moran's I=0·02). An exposure-response association was observed, with an additional average decrease in alcohol-related hospital admission rates in the areas with the highest intensity policies compared with passive areas of 2% annually (95% CI −3 to −2, p=0·006). Accounting for other population changes, this equated to a modest additional 5% reduction, or about eight unique admissions per 100 000 people, in 2015 compared with what would have been expected had these areas not had active policies in place.InterpretationAlthough these analyses do not directly prove causality, they add to the available evidence about the efficacy of alcohol licensing policies specifically for England. Despite the fairly modest average effect, the intensity of alcohol licensing policies implementation and enforcement is related to measurable health gain.FundingThis work was funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR).     

Maternal care during infancy regulates the development of neural systems mediating the expression of fearfulness in the rat

The mothers of infant rats show individual differences in the frequency of licking/grooming and arched-back nursing (LG-ABN) of pups that contribute to the development of individual differences in behavioral responses to stress. As adults, the offspring of mothers that exhibited high levels of LG-ABN showed substantially reduced behavioral fearfulness in response to novelty compared with the offspring of low LG-ABN mothers. In addition, the adult offspring of the high LG-ABN mothers showed significantly (i) increased central benzodiazepine receptor density in the central, lateral, and basolateral nuclei of the amygdala as well as in the locus ceruleus, (ii) increased α₂ adrenoreceptor density in the locus ceruleus, and (iii) decreased corticotropin-releasing hormone (CRH) receptor density in the locus ceruleus. The expression of fear and anxiety is regulated by a neural circuitry that includes the activation of ascending noradrenergic projections from the locus ceruleus to the forebrain structures. Considering the importance of the amygdala, notably the anxiogenic influence of CRH projections from the amygdala to the locus ceruleus, as well as the anxiolytic actions of benzodiazepines, for the expression of behavioral responses to stress, these findings suggest that maternal care during infancy serves to “program” behavioral responses to stress in the offspring by altering the development of the neural systems that mediate fearfulness.     

Fetal growth restriction and cardiovascular outcome in early human infancy: a prospective longitudinal study

The association between low birth weight and premature cardiovascular disease has led to the “prenatal origin of adult disease-hypothesis”. We postulated that fetal growth restriction is associated with cardiovascular changes detectable at birth and in early infancy. Fifty-two appropriately grown fetuses (AGA) and 60 growth-restricted fetuses (FGR) with (n = 20) or without (n = 40) absent or reversed end-diastolic umbilical artery blood flow were prospectively examined by echocardiography before birth, at 1 week and 6 months of life. The impact of growth restriction on postnatal blood pressure, heart rate, cardiovascular dimensions, and function, as well as on vascular morphology of umbilical cord vessels was studied. FGR fetuses displayed significant blood flow redistribution and were delivered earlier with lower birth weights than AGA fetuses. After adjustment for gender, gestational age, and weight at birth, there were no intergroup differences in blood pressure, heart rate, left ventricular morphology, mass, and performance, and in cord vessel morphology. During the first 6 months of life brachioradial pulse wave velocity increased more in FGR fetuses, while other parameters describing vascular stiffness remained comparable between the groups. Fetal growth restriction had no detectable adverse impact on cardiovascular dimensions and function at birth. Cardiovascular findings also remained comparable during the first 6 months of life between the groups except a higher increase in brachioradial pulse wave velocity in the FGR group. Our observations suggest that abnormalities that link reduced intrauterine growth with premature cardiovascular diseases may commence later in childhood, indicating a potential window for screening and prevention.     

Social deprivation as a marker for alcohol harms,and implications for local harm reduction policies in England: an ecological study

Background

Cumulative impact policies restricting the award of new licences to sell alcohol have been implemented in many local authorities across England as a means of tackling alcohol harms. Providing evidence linking local harms with availability, however, can present practical challenges for public health teams. We sought to examine the extent to which measures of availability together with local small area characteristics were associated with both acute and chronic alcohol harms in a local authority in north east England.

Bone loss rate in adrenal incidentalomas: a longitudinal study.

Although by definition patients with adrenal incidentalomas (AI) do not have evident clinical syndromes, they may frequently suffer from subclinical hypercortisolism (SH). This is of some importance because of evidence that SH may lead to clinical complications, including bone loss. Thus, the understanding of bone involvement due to SH may be extremely important in the management of AI. Unfortunately, the available data on bone mineral density (BMD) in AI patients come from cross-sectional studies, which, to further complicate our understanding, are also conflicting, probably due to a different selection of patients and/or the variability in cortisol secretion (CS) often described in AI. To gain further insight about this topic, we performed a longitudinal study evaluating the rate of spinal and femoral bone loss levels in 24 females with AI. AI subjects were subdivided in two groups on the basis of the median of urinary cortisol secretion (UFC): group I (n = 12; UFC, <140.4 nmol/24 h) and group II (n = 12; UFC, >140.4 nmol/24 h). Spinal BMD was measured by both single energy quantitative computed tomography (L1-L4) and dual energy x-ray absorptiometry (DXA; L2-L4), and femoral BMD was determined by DXA. Bone loss rate was expressed as the change in z-score per yr. The spinal bone loss rate was higher (P < 0.005) in group II than in group I when measured by both quantitative computed tomography (-0.19 +/- 0.14 vs. 0.00 +/- 0.15) and DXA (-0.19 +/- 0.17 vs. 0.00 +/- 0.11). Moreover, CS and spinal bone loss rate were significantly correlated when patients were considered together. In conclusion, our data show that 1) AI patients with higher CS have increased lumbar trabecular bone loss rate than those with lower CS; and 2) the degree of spinal bone loss rate is related to the degree of CS. Thus, lumbar spine (LS) BMD has to be evaluated for well balanced decision-making on the treatment of choice for AI female patients.     

Blood pressure and cardiac output during exercise: a longitudinal study of children undergoing repair of coarctation

Data were examined from 21 children who underwent graded exercise studies prior to and within 5 years after repair of coarctation. A control group of 10 normal children was also studied longitudinally on two occasions. The exercise was performed on an upright bicycle ergometer using a continuous graded exercise protocol. Parameters measured were heart rate, systolic and diastolic blood pressure at rest, and these pressures at the maximal voluntary exercise level. In addition, a subset of patients and controls had measurement of cardiac output by a modified acetylene rebreathing technique. Results indicate that coarctation patients had significant elevation of systolic and diastolic blood pressures at rest (p less than 0.001 for both) and with exercise (p less than 0.02 for both) prior to surgery. The group mean values for systolic and diastolic blood pressure did not differ from control values after surgery; however, some individuals continued to have hypertension at rest when compared to population-based norms. Heart rate, cardiac index, and stroke volume index did not differ from those of control subjects either at rest or during exercise before or after surgery. In conclusion, a group of coarctation patients studied longitudinally demonstrated marked improvement in both systolic and diastolic hypertension after surgery. The findings of normal cardiac output and stroke volume indices may have implications for the etiology of postoperative hypertension.     

Rotavirus associated diarrhoea during infancy in the city of S. Luís (MA), Brazil: a two-year longitudinal study.

A total of 479 diarrhoeic children and 337 children without diarrhoea (controls) less than 5 years old were investigated in a two-year study in the city of S. Luís (MA), with the purpose to determine the incidence, the age distribution and the seasonality of rotaviruses, as well as to establish the severity of the disease in this region between the North and the Northeast of Brazil. rotavirus incidence was highest in children of the 1st. year of life, showing an average of 25% per year among the diarrhoeic patients attending the two main hospitals and three health units at the periphery of the city. It was shown that rotaviruses are significant enteropathogens in children less than 18 months old. Frequency of rotaviruses dropped in diarrhoeic patients 18 to 23 months old to only 4%, the same percentage observed in children of the control group. A typical seasonal distribution of rotaviruses was not seen during the two years of study. There was a peak in the incidence of rotaviruses in 1986, during the rainy season, and two peaks in 1987, one in the rainy season and one in the dry season. It was also shown that severity of diarrhoea in rotavirus positive cases was higher than in the negative cases. Rotavirus diarrhoeic patients had more loose stools per day, and higher frequencies of vomiting and fever, resulting more often (> 2 times) in moderate or severe dehydration. Finally, it is concluded that the introduction of immunoprophylaxis may reduce significantly the high mortality rates in early childhood observed in S. Luís.     

Outcomes of venous ulcer care: results of a longitudinal study

A longitudinal study involving 81 patients with venous ulcers was conducted to explore the outcomes and cost of wound care in a home healthcare (HHC) setting and an outpatient care setting. Ulcers were managed with a saline gauze or hydrocolloid dressing and compression hosiery, or covered with an Unna's boot. Outcomes did not vary between physician's office and home care. Patients preferred home care, but costs and charges were much higher for HHC than for patients managed in the physician's office. Recurrence rates and costs varied greatly. Eighty-eight percent of ulcers in the saline dressing group did not heal or recurred compared to 21% of ulcers in the Unna's boot and 13% of ulcers in the hydrocolloid dressing group. The data also suggest hydrocolloid dressings are more cost-effective than Unna's boot or saline-gauze dressings. Controlled clinical studies to ascertain the cost-effectiveness of venous ulcer care in different patient care settings and the use of different treatment modalities, as well as care system oriented toward outcome for the patient rather than service, design, and distribution, are needed.     

Spirometric variability in a longitudinal study of school-age children

OBJECTIVES: To describe spirometric reproducibility in a longitudinal study of students from Mexico City, and also the frequency of subjects fulfilling quality criteria proposed for children. SUBJECTS AND METHODS: Three thousand three hundred forty-seven participants from the third through sixth grades of elementary school were recruited to perform biannual spirometry, yielding a maximum of seven evaluations and a total of 15,563 tests. Standard recommendations of the American Thoracic Society (ATS) were followed, using dry rolling-seal volume spirometers. RESULTS: During their first spirometric test, > 95% of the subjects fulfilled each of the quality criteria proposed by ATS for adults, though not all of them did so simultaneously. For example, only 72.4% obtained three acceptable maneuvers, reproducibility for FEV(1) and FVC to < 200 mL, and a small back-extrapolated volume that increased to 92.3% by the second test. Between phase 1 and phase 7 of the study, spirometry quality increased significantly, as a result of subject and technician training. Intratest and intertest (with a 6-month difference) spirometric variability was less in boys than in girls. Intratest variability was also lower in younger and taller subjects. Technicians contributed significantly to intratest and intertest variability, the latter decreasing if the same technician performed both evaluations. CONCLUSION: Children > 7 years old can fulfill ATS criteria of quality after the first spirometric evaluation. To maintain quality of spirometric tests in longitudinal studies of children, a strict control is required, especially of technician performance.     

Seasonal variation in the internet searches for gout: an ecological study

Clinical Rheumatology - While few studies with various types of outcomes and methodology have investigated the seasonality of gout, no internet data has been used in any study. This novel...     

Investigating local policy drivers for alcohol harm prevention: a comparative case study of two local authorities in England

BackgroundThe recent transfer of public health teams to local authorities in England offers opportunities for new policy approaches to tackling alcohol harm. The new responsible authority status of directors of public health, for example with regard to licensing applications, raises the prospect of reducing excessive alcohol consumption through local availability measures. Local authorities are also responsible for the commissioning of community-based treatment services. We used a case study approach to identify the major drivers and characteristics of local alcohol policies and services in two contrasting local authorities.MethodsThe many sources used were semi-structured interviews with key informants, including two in public health, two in licensing and trading standards, one in the police, and one information specialist; documentary analysis, including two alcohol strategies; two statements of licensing policy; and field observation (attending a licensing committee hearing). Focusing on alcohol harm prevention programmes and their underlying objectives, we used storyboards and constant comparative methods to describe and explain differences in the alcohol policy landscape between the two local authorities. Ethics approval was obtained from the University of Sheffield Ethics Committee.FindingsSubstantial differences in the stated priorities of alcohol harm prevention strategies were shown in the contrasting policy responses of the two local authorities. Concern about how best to reduce high rates of alcohol-related hospital admissions in local authority 1 led to an emphasis on health-service approaches, such as screening and brief intervention, whereas a public disorder focus in local authority 2 resulted in policies aimed at reducing availability through licensing measures. Perceived tensions were apparent for local authority 1 between maintaining a supportive environment for local businesses at a time of economic recession and introducing policy measures with a regulatory focus. Field observations highlighted the underlying importance of well-functioning working relationships between licensees and all responsible authorities, for achieving acceptable implementation plans for novel policies. Resource constraints and a lack of clear policy champions were also barriers to more preventive measures in local authority 1.InterpretationDevolved responsibility for alcohol harm prevention clearly presents the potential for local authorities to tailor policies closely to their identified population needs. The exercising of responsible authority status in reducing availability through licensing approaches is best achieved however when fully integrated into the full spectrum of alcohol harm reduction activities, from prevention through to treatment-based interventions.FundingJDM's post is fully funded by the National Institute for Health Research School for Public Health Research School-wide Programme on Alcohol.     

Gastroesophageal reflux symptoms during and after pregnancy: a longitudinal study

BACKGROUND AND AIMS: Prevalence of gastroesophageal reflux symptoms (GERS) increases during pregnancy, but there are no longitudinal studies on western populations examining their incidence in each trimester. Our aim was to describe the natural history of GERS in pregnancy and to ascertain whether pregnancy might be associated with a higher risk of developing GERS 1 yr postpartum. METHODS: Pregnant women (<12 wk gestation) and age-matched controls were included. A telephone survey was conducted, covering pregnant women at 12, 24, and 36 wk of gestation and at 1 yr postpartum, using a validated questionnaire. Controls were interviewed at baseline and 21 months later. RESULTS: Data on 263 pregnant women were analyzed. Incidence of GERS was 25.8% (95% confidence interval [CI] 20.1-31.1%) in the first trimester, 24.3% (95% CI 18.1-30.6%) in the second, and 25.5% (95% CI 18.2-32.8%) in the third. Factors associated with developing GERS in the first trimester were South American origin (odds ratio [OR] 2.75, 95% CI 1.30-5.84) and prepregnancy occasional GERS (OR 3.00, 95% CI 1.35-6.66). Risk factors of GERS in the third trimester were cumulative weight gain during pregnancy (OR 1.18, 95% CI 1.04-1.32) and prepregnancy occasional GERS (OR 3.79, 95% CI 1.08-13.24). Incidence of frequent GERS at 1 yr postpartum was higher in pregnant versus control women (4.7%vs 1.3%, P < 0.05). CONCLUSIONS: Incidence of GERS is similar across the three trimesters of pregnancy. Accumulated weight gain during pregnancy is associated with a higher risk of GERS in the third trimester. Pregnancy might constitute a risk factor for developing GERS 1 yr postpartum.     

Tobacco use in local authority children's homes: a socioecological exploration of influences

BackgroundResearch on tobacco use among looked-after children (LAC) has primarily focused on the individual characteristics of young people in care. We aimed to conceptualise additional factors influencing tobacco use by young people living in English local authority children's homes from a policy and provider perspective.MethodsWe did a socioecological analysis of existing data, which included an evaluation of LAC health assessment documentation (n=31 cases), a survey of residential carers in six local authorities in the East Midlands (n=42 respondents), and semi-structured interviews with residential carers (n=14) working in three children's homes operated by one local authority in the East Midlands. We thematically coded and mapped these data to the social ecological model for health promotion to identify and understand the interplay of influences on tobacco use. Collaborative consensus was reached on coding and interpretation. We chose the social ecological model for its potential to answer questions about how to address tobacco use and highlight potential leverage points.Findings32 factors influencing tobacco use were identified: intrapersonal level (n=10), interpersonal level (n=9), institutional level (n=6), community level (n=3), and macro-organisational (policy) level (n=4). The challenge of balancing child protection responsibilities and safeguarding, with expected parenting practices were highlighted. Institutional, organisational, and community strategies were found to facilitate tobacco use. For example, provision of designated smoking areas in the grounds of the homes and the ease at which young people can purchase tobacco in the local area were compounded by the scarcity of policy monitoring and information sharing at the macro-organisational level. Some data fell outside of individual chose the social ecological model levels, requiring a degree of researcher interpretation.InterpretationVarious influences across and within multiple levels of the care system might complicate and compound typical youth smoking influences and measures to address them. We recommend that, in the development of smoke-free children's home policies, local authorities should be guided by the experiences and knowledge of carers and be cognisant of previous implementation challenges or successes to enable informed and contextually relevant strategies to be developed and implemented. This study offers a much-needed direction for developing and testing tobacco-related interventions targeting this vulnerable population.FundingUniversity of Nottingham PhD studentship and the UK Centre for Tobacco and Alcohol Studies.