Not all non-drinkers with HIV are equal: demographic and clinical comparisons among current non-drinkers with and without a history of prior alcohol use disorders*

Studies of persons living with HIV (PLWH) have compared current non-drinkers to at-risk drinkers without differentiating whether current non-drinkers had a prior alcohol use disorder (AUD). The purpose of this study was to compare current non-drinkers with and without a prior AUD on demographic and clinical characteristics to understand the impact of combining them. We included data from six sites across the US from 1/2013 to 3/2015. Patients completed tablet-based clinical assessments at routine clinic appointments using the most recent assessment. Current non-drinkers were identified by AUDIT-C scores of 0. We identified a prior probable AUD by a prior AUD diagnosis in the electronic medical record (EMR) or a report of attendance at alcohol treatment in the clinical assessment. We used multivariate logistic regression to examine factors associated with prior AUD. Among 2235 PLWH who were current non-drinkers, 36% had a prior AUD with more patients with an AUD identified by the clinical assessment than the EMR. Higher proportions with a prior AUD were male, depressed, and reported current drug use compared to non-drinkers without a prior AUD. Former cocaine/crack (70% vs. 25%), methamphetamine/crystal (49% vs. 16%), and opioid/heroin use (35% vs. 7%) were more commonly reported by those with a prior AUD. In adjusted analyses, male sex, past methamphetamine/crystal use, past marijuana use, past opioid/heroin use, past and current cocaine/crack use, and cigarette use were associated with a prior AUD. In conclusion, this study found that among non-drinking PLWH in routine clinical care, 36% had a prior AUD. We found key differences between those with and without prior AUD in demographic and clinical characteristics, including drug use and depression. These results suggest that non-drinkers are heterogeneous and need further differentiation in studies and that prior alcohol misuse (including alcohol treatment) should be included in behavioural health assessments as part of clinical care.     

Medical students' experience of vaginal examinations of anaesthetised women

Medical students usually initially learn vaginal examination (VE) by examining consenting anaesthetised women. To assess their experience of this practice, a questionnaire was distributed to all 66 fifth-year students at the Wellington School of Medicine in 2005—53 students responded. Although 184 women were available to approach for consent, only 141 were approached—students claimed insufficient time as their major difficulty. All male students discussed consent with women only in the 2 hours preoperatively, whereas nine (28%) of the female students sought consent earlier on the day or the day before. Of the 114 women asked, 97 gave written consent, but the VE was conducted in only 76 women mostly because the supervising gynaecologist claimed time constraints or was uninterested. Four other women were examined when consent was uncertain and two without consent. All but one of the students considered the experience educationally valuable. Eleven responding students did not perform a VE, and if the 13 nonresponders also did not, more than one-third of students lack this educational opportunity prior to their final year. In conclusion, some students require more commitment to seeking consent, and some gynaecologists may need to better facilitate this learning opportunity so that the consent agreed with the woman and student is more often respected.     

Differences in tobacco assessment and intervention practices: a regional snapshot

BACKGROUND: This research describes tobacco attitudes and practices of health care providers in the Upper Midwest. A baseline measure of preventive practices by providers was needed to plan effective tobacco intervention education programs. METHODS: Health care providers in a 16-county region received a mailed survey regarding tobacco assessment practices, intervention practices, attitudes, skills/knowledge, barriers, and desire for tobacco education. The survey was sent to all chiropractors, dentists, nurse practitioners/physician assistants, physicians (primary care and specialist), and public health nurses in the region. A total of 51.9% (n = 614) of all providers returned usable surveys. RESULTS: Significant differences were found between provider groups on all measured concepts. Primary care physicians, nurse practitioners/physician assistants, and public health nurses were more likely than specialist physicians, dentists, and chiropractors to assess, intervene, be supportive of tobacco cessation, have skills/knowledge about cessation, perceive fewer barriers, and want further education. CONCLUSIONS: In this region, provider groups differed in tobacco use assessment and treatment. All provider groups desired education regarding tobacco intervention. Region-wide tobacco cessation educational initiatives need to take into account differences between provider groups.     

Clinical correlates of early medication adherence: West London first episode schizophrenia study

OBJECTIVE: Little is known about factors that mediate adherence with medication during the early stages of antipsychotic treatment in schizophrenia. This study sought to identify factors that may be associated with medication adherence in first-episode schizophrenia. METHOD: In 101 patients, adherence was assessed along with potentially relevant variables, including attitudes toward medication, insight, substance misuse, side effects and psychopathology. RESULTS: In a linear regression analysis, negative attitudes toward medication and a relative lack of insight contributed significantly towards poor adherence. Although poorly adherent patients had significantly higher scores on negative and disorganization syndromes, these did not contribute significantly towards adherence. Adverse medication side effects, subjective well-being and substance misuse showed no significant association with adherence. CONCLUSION: At the initiation of drug treatment, attitudes toward medication and insight appear more relevant to medication adherence than side effects. Adherence appears to reflect a complex interaction of influences, which may change over time.     

A polymorphism in the alpha4 nicotinic receptor gene (Chrna4) modulates enhancement of nicotinic receptor function by ethanol

BACKGROUND: Several studies indicate that ethanol enhances the activity of alpha4beta2 nicotinic acetylcholine receptors (nAChR). Our laboratory has identified a polymorphism in the alpha4 gene that results in the substitution of an alanine (A) for threonine (T) at amino acid position 529 in the second intracellular loop of the alpha4 protein. Mouse strains expressing the A variant have, in general, greater nAChR-mediated 86Rb+ efflux in response to nicotine than strains with the T variant. However, the possibility of the polymorphism modulating the effects of ethanol on the 86Rb+ efflux response has not been investigated. METHODS: We have used the 86Rb+ efflux method to study the acute effects of ethanol on the function of the alpha4beta2 nAChR in the thalamus in six different mouse strains. Experiments were also performed on tissue samples taken from F2 intercross animals. The F2 animals were derived from A/J mice crossed with a substrain of C57BL/6J mice that carried a null mutation for the gene encoding the beta2 nAChR subunit. RESULTS: In strains carrying the A polymorphism (A/J, AKR/J, C3H/Ibg), coapplication of ethanol (10-100 mM) with nicotine (0.03-300 microM) increased maximal ion flux when compared with nicotine alone with no effect on agonist potency. In contrast, ethanol had little effect on the nicotine concentration-response curve in tissue prepared from strains carrying the T polymorphism (Balb/Ibg, C57BL/6J, C58/J). Experiments with the F2 hybrids demonstrated that one copy of the A polymorphism was sufficient to produce a significant enhancement of nAChR function by ethanol (50 mM) in animals that were also beta2 +/+. Ethanol had no effect on nicotine concentration-response curves in T/T beta2 +/+ animals. CONCLUSIONS: The results suggest that the A/T polymorphism influences the initial sensitivity of the alpha4beta2 nAChR to ethanol.     

Deprivation and stillbirth risk in rural and urban areas

The objective of the study was to investigate whether stillbirth risk was higher, and the effect of deprivation on inequality in stillbirth risk more marked, in rural than in urban areas. We carried out a cohort study of all 280 757 singleton births to mothers domiciled in Cumbria, north-west England, 1950-92. After allowing for individual social class and community deprivation, the risk of stillbirth was lower outside urban centres both during 1950-65 (OR = 0.91, 95% CI 0.84, 1.00) and during 1966-92 (OR = 0.82, 95% CI 0.73, 0.92). In earlier years, unsupported mothers in rural areas and mothers living in remote areas were particularly at risk. Urban/rural differences in risk were not explained by individual social class, community deprivation or overcrowding and have persisted over a 40-year time period.     

Aggregate data meta-analysis with time-to-event outcomes

In a meta-analysis of randomized controlled trials with time-to-event outcomes, an aggregate data approach may be required for some or all included studies. Variation in the reporting of survival analyses in journals suggests that no single method for extracting the log(hazard ratio) estimate will suffice. Methods are described which improve upon a previously proposed method for estimating the log(HR) from survival curves. These methods extend to life-tables. In the situation where the treatment effect varies over time and the trials in the meta-analysis have different lengths of follow-up, heterogeneity may be evident. In order to assess whether the hazard ratio changes with time, several tests are proposed and compared. A cohort study comparing life expectancy of males and females with cerebral palsy and a systematic review of five trials comparing two anti-epileptic drugs, carbamazepine and sodium valproate, are used for illustration.