Routine Alcohol Research Articles

A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center.

BackgroundUnhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients.MethodsWe conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting.ResultsA total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features.ConclusionsRCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients.

Drinking frequency as a brief screen for adolescent alcohol problems.

Routine alcohol screening of adolescents in pediatric settings is recommended, and could be facilitated by a very brief empirically validated alcohol screen based on alcohol consumption. This study used national sample data to test the screening performance of 3 alcohol consumption items (ie, frequency of use in the past year, quantity per occasion, frequency of heavy episodic drinking) in identifying youth with alcohol-related problems. Data were from youth aged 12 to 18 participating in the annual National Survey on Drug Use and Health from 2000 to 2007. The screening performance of 3 alcohol consumption items was tested, by age and gender, against 2 outcomes: any Diagnostic and Statistical Manual, Fourth Edition alcohol use disorder symptom ("moderate"-risk outcome), and a diagnosis of Diagnostic and Statistical Manual, Fourth Edition alcohol dependence ("high"-risk outcome). Prevalence of the 2 outcomes increased with age: any alcohol use disorder symptom ranged from 1.4% to 29.2%; alcohol dependence ranged from 0.2% to 5.3%. Frequency of drinking had higher sensitivity and specificity in identifying both outcomes, compared with quantity per occasion and heavy episodic drinking frequency. For both outcomes, results indicate the utility of similar cut points for drinking frequency for males and females at each age. Age-specific frequency cut points, however, are recommended for both moderate- and high-risk outcomes to maximize screening performance. Drinking frequency provides an empirically supported brief screen to efficiently identify youth with alcohol-related problems.

Tobacco, Caffeine, Alcohol and Illicit Substance Use Among Consumers of a National Psychiatric Disability Support Service

Previous research has consistently documented high rates of tobacco smoking and substance use disorders among young people with serious mental illness. However, limited studies have been conducted outside traditional clinical settings. In an attempt to address this shortfall and to better understand the needs of young people accessing its services, a national psychiatric disability support service (Neami) examined the prevalence and impact of substance use among 120 consumers from across Australia aged 30 years and under. Results indicated extremely high rates of tobacco use, with 68% of participants identified as daily smokers. In addition, 33.4% met criteria for an alcohol use disorder, whilst 40.8% met criteria for a cannabis use disorder. Overall rates of other illicit substance use were low. This study reinforces the need for routine alcohol and drug screening and assessment across all mental health settings, as well as appropriate support strategies that address high level smoking and caffeine intake.

Urinary ethyl glucuronide as a novel screening tool in patients pre- and post–liver transplantation improves detection of alcohol consumption

Optimal selection of liver transplant candidates and early detection of alcohol relapse after orthotopic liver transplantation (OLT) is necessary to improve long-term outcomes. In this study, urinary ethyl glucuronide (uEtG) was prospectively evaluated as a novel screening tool for alcohol detection in the transplant setting. Overall, 141 liver transplant candidates and recipients, visiting the outpatient clinic for a total of 308 times, were included. At each visit, the alcohol markers, uEtG, ethanol, methanol, and carbohydrate-deficient transferrin (CDT), as well as the state markers, alanine transaminase, aspartate transaminase, gamma glutamyl transpeptidase (GGT), and mean corpuscular volume (MCV), were determined, then compared to patients' self-reports on alcohol intake. Urinary EtG significantly increased the detection rate of alcohol consumption, compared to the other alcohol markers (P < 0.001). In 93% of patients and at 92.5% of visits with positive alcohol markers, alcohol intake was detected by uEtG and/or CDT. Sensitivity and specificity of uEtG were 89.3% and 98.9% and of CDT were 25% and 98.6%, respectively. Urinary EtG was the best independent predictor of alcohol consumption in univariate and multivariate analysis (positive predictive value: 89.3%; negative predictive value: 98.9%; odds ratio: 761.1; P < 0.001). It showed a superior prediction rate, when compared to established alcohol and state markers, as well as to the combination of CDT with MCV and GGT, assessed by net reclassification improvement (NRI) (NRI: 1.01, P < 0.001; NRI: 1.755, P < 0.001). uEtG is a sensitive, specific, and reliable marker for the detection of recent alcohol intake pre- and post-OLT. In combination with CDT, uEtG should be considered as a tool for routine alcohol screening within the transplant setting.

Drivers of Male Perpetration of Family and Intimate Partner Violence in Cape Town

This paper examines the drivers of male perpetration of violence against adultfamily members and intimate partners in Cape Town, South Africa. Data on 1,369 young men from the Cape Area Panel Study are analyzed and significant causal pathways are examined for the full sample and for disaggregated samples of African and coloured respondents. Socioeconomic disadvantage plays a role in a culture of patriarchal violence, but its effects are largely mediated by behavioural factors such as routine alcohol consumption and having concurrent sexual partners, and norms of acceptance of violence against women. Different factors emerge as predictors of violence in the African and coloured samples. The findings of the quantitative analysis are illustrated with evidence from 45 qualitative interviews that address the role of violence in family and gender relations in Cape Town. Economic interventions are of uncertain efficacy given South Africa‘s difficulties since the end of apartheid in improving economic opportunities for the poor; thus interventions targeting norms and behaviour hold the most promise for reducing family and intimate partner violence in the near term.

Forgiveness and the Bottle: Promoting Self-Forgiveness in Individuals Who Abuse Alcohol

ABSTRACT In the current article, the authors explore the efficacy of a 4-hour self-forgiveness intervention. Participants (n = 79) undergoing a routine alcohol treatment protocol were randomly assigned to an intervention or treatment as usual condition. Those in the intervention condition completed the self-forgiveness intervention. All participants completed measures of self-forgiveness, drinking refusal self-efficacy, and guilt and shame over an alcohol-related transgression. Participants in the intervention condition reported more positive gains on measures of self-forgiveness and drinking refusal efficacy, as well as guilt and shame over alcohol-related offenses. Implications of the self-forgiveness intervention for individuals who misuse alcohol are discussed.

The clinical course of rapidly growing nontuberculous mycobacterial peritoneal dialysis infections in Asians: A case series and literature review

Peritoneal dialysis (PD)-related infections due to rapidly growing nontuberculous mycobacterium (RGNTM) are rare in Asians and have variable clinical outcomes. We analysed retrospectively a series of RGNTM infections in a single-centre multi-ethnic Asian population over a 5-year period. Clinical features, treatment, risk factors and outcomes are discussed. Ten infections are described. They constituted 3% of all culture-positive exit site infection (ESI) and PD peritonitis. Seventy percent were due to Mycobacterium abscessus (three ESI and four peritonitis). There were two Mycobacterim fortuitum and one Mycobacterium chelonei peritonitis. No specific findings differentiated RGNTM infections from those caused by traditional organisms. Six cases had received prior antibiotics, two being topical gentamicin. Initial routine culture and alcohol acid fast bacillus were negative except for one case of M. abscessus. A confirmatory diagnosis was made a median 9 days post culture. No infection responded to routine antibiotics. Antibiotic resistance was variable but M. abscessus was universally sensitive to clarithromycin. Combined antibiotics based on sensitivity profile were successfully used in 70% of the cases. PD catheter loss was 80%. Three-month mortality was 40% (vs. 8.5% and 12% in non-RGNTM ESI and peritonitis, respectively). This may be related to the cohort high mean Charlson score of 7.5. RGNTM PD infections are commoner in Asians than previously reported. Their early diagnosis requires a high index of suspicion and appropriate treatment started promptly. They are associated with prior antibiotic use and refractory culture-negative infections, delayed diagnosis and lead to significant catheter loss and death.

10.2478/s11814-009-0294-4

The scale-up of cell-free protein synthesis reactions involves the preparation of large amounts of template DNA. While ion-exchange column chromatography methods have commonly been used to obtain purified plasmid DNA for cell-free protein synthesis reactions, these methods are costly and difficult to expand to a large scale. In this work, we report that the routine isopropyl alcohol (IPA) precipitation method can be used to prepare cell-free-expressible DNA when the co-precipitated proteins are removed. Compared to column-purification procedures, the IPA-precipitation offers obvious advantages with respect to the cost and scaling-up of template preparation, and we believe that our finding will contribute to making cell-free protein synthesis system more practical for the rapid production of preparative amounts of recombinant proteins.

Embedding routine alcohol screening and brief interventions in a rural general hospital

Alcohol screening and brief intervention approaches (SBI) are strongly supported by evidence, but few health-care facilities have successfully introduced and sustained routine SBI. This paper describes the first 2 years of implementing SBI in an Australian rural general hospital. The SBI project aims were to universally screen presentations to Northeast Health Wangaratta (NHW), to provide brief interventions to people screening at medium risk of harm from drinking and enhanced referral for persons screening at high risk. In 2007 and 2008, the NHW SBI project conducted 11,079 screens for alcohol use disorders using the Alcohol Use Disorders Identification Screening Test screening tool. Eighty-five per cent of persons screened at low risk of alcohol-related problems, 11% at medium risk and 4% at high risk. Policy and planning bodies and hospital management's support and the appointment of a dedicated project worker are critical to successful SBI implementation. It is possible to establish a SBI service in a rural general hospital setting. The NHW SBI project broadened the focus from treatment of persons with severe dependency to detection, early intervention and prevention for the larger, more easily treated, cohort of persons drinking at hazardous/harmful but non-dependent levels. The challenge for any organisation is to maintain routine SBI deployment over the long term.

Guidelines for allocating outpatient alcohol abusers to levels of care: Predictive validity

The purpose of this study was to assess the predictive validity of guidelines for allocating outpatients with an alcohol-use disorder to different levels of care in routine alcohol outpatient treatment facilities. It was hypothesized that patients matched to the recommended level of care would have (a) better outcomes than patients treated at a less intensive level of care, and (b) outcomes equivalent to patients treated at a more intensive level of care.Patients at two Dutch substance-abuse treatment centers who completed intake and were allocated at either a brief or standard outpatient treatment (n=471) were followed prospectively to determine differential outcomes for those who were and were not treated at the recommended level of car. The former patients were allocated according to an algorithm based on their treatment history, addiction severity, psychiatric impairment and social stability at baseline. 52.9% of the original sample was successfully contacted for follow-up 11months after intake.Outcome was measured in terms of self-reported alcohol use 30days prior to follow up and changes in number of excessive and nonexcessive drinking days between intake and follow up.Only 21% of the patients were matched to the level of care according to the guidelines. Patients allocated to the recommended level of care did not have better outcomes than those treated at a less intensive level of care, but they had outcomes comparable to patients treated at a more intensive level of care. The a priori allocation guidelines were followed for only a minority of the patients, and using them did not improve treatment outcome. Further work is needed to improve the content of the treatment allocation guidelines.

Telephonic screening and brief intervention for alcohol misuse among workers contacting the employee assistance program: A feasibility study

Substantial empirical support exists for alcohol screening, brief intervention, and referral to treatment (SBIRT) in medical, but not non-medical settings such as the workplace. Workplace settings remain underutilised for delivering evidenced-based health services. This research aims to translate medical research into behavioural health-care practice in a telephonic call centre acting as a point of entry into an Employee Assistance Program (EAP). The goal of the study is to examine the feasibility of implementing routine telephonic alcohol SBIRT in an EAP call centre and assess whether routine SBIRT results in increased identification of workers who misuse alcohol. The design was pretest-posttest, one-group, pre-experimental. An alcohol SBIRT program developed based on World Health Organization recommendations was implemented in one EAP call centre serving one large employer. Workers were offered screening using the Alcohol Use Disorder Identification Test (AUDIT) during intake, brief counselling using motivational interviewing, referral to counselling, and follow-up. At 5 months, 93% of workers contacting the EAP completed the AUDIT-C: 40% prescreened positive and 52% went on to screen at moderate or high risk for an alcohol problem. Overall identification rate (18%) approached general US population estimates. Most agreed to follow-up and three-quarters set an appointment for face-to-face counselling. Integration of routine alcohol SBIRT into EAP practice is feasible in telephonic delivery systems and increases identification and opportunity for brief motivational counselling. When SBIRT is seamlessly integrated workers are willing to answer questions about alcohol and participate in follow-up.[McPherson TL, Goplerud E, Derr D, Mickenberg J, Courtemanche S. Telephonic screening and brief intervention for alcohol misuse among workers contacting the employee assistance program: A feasibility study.

A Characterization of Sources of Isopropanol Detected on Postmortem Toxicologic Analysis

Isopropanol is an important chemical to forensic pathologists in that intoxication can result in death yet presence does not necessarily indicate intoxication. Several reports have been published, which indicate that isopropanol can be created endogenously in certain situations including diabetes mellitus, starvation, dehydration, and chronic ethanol use; however, a large-scale analysis addressing all of the possible causes of postmortem isopropanol detection has not been performed. A retrospective review of all cases examined at the Bexar County Medical Examiner's Office between 1993 and 2008 in which isopropanol was detected in routine alcohol screening was undertaken. The cases were categorized by the source of the isopropanol, and the concentrations of isopropanol and acetone were analyzed. Analysis revealed isopropanol concentrations to be low (<100 mg/dL) in cases of antemortem and postmortem creation and in postmortem contamination and high (>100 mg/dL) in cases of antemortem exposure. These results are consistent with other published reports.

Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients: Design and Implementation.

While the integration of alcohol screening, treatment, and referral in primary care and other medical settings in the U.S. and worldwide has been recognized as a key health care priority, it is not routinely done. In spite of the high co-occurrence and excess mortality associated with alcohol use disorders (AUDs) among individuals with tuberculosis (TB), there are no studies evaluating effectiveness of integrating alcohol care into routine treatment for this disorder. We designed and implemented a randomized controlled trial (RCT) to determine the effectiveness of integrating pharmacotherapy and behavioral treatments for AUDs into routine medical care for TB in the Tomsk Oblast Tuberculosis Service (TOTBS) in Tomsk, Russia. Eligible patients are diagnosed with alcohol abuse or dependence, are newly diagnosed with TB, and initiating treatment in the TOTBS with Directly Observed Therapy-Short Course (DOTS) for TB. Utilizing a factorial design, the Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients (IMPACT) study randomizes eligible patients who sign informed consent into 1 of 4 study arms: (1) Oral Naltrexone + Brief Behavioral Compliance Enhancement Therapy (BBCET) + treatment as usual (TAU), (2) Brief Counseling Intervention (BCI) + TAU, (3) Naltrexone + BBCET + BCI + TAU, or (4) TAU alone. Utilizing an iterative, collaborative approach, a multi-disciplinary U.S. and Russian team has implemented a model of alcohol management that is culturally appropriate to the patient and TB physician community in Russia. Implementation to date has achieved the integration of routine alcohol screening into TB care in Tomsk; an ethnographic assessment of knowledge, attitudes, and practices of AUD management among TB physicians in Tomsk; translation and cultural adaptation of the BCI to Russia and the TB setting; and training and certification of TB physicians to deliver oral naltrexone and brief counseling interventions for alcohol abuse and dependence as part of routine TB care. The study is successfully enrolling eligible subjects in the RCT to evaluate the relationship of integrating effective pharmacotherapy and brief behavioral intervention on TB and alcohol outcomes, as well as reduction in HIV risk behaviors. The IMPACT study utilizes an innovative approach to adapt 2 effective therapies for treatment of alcohol use disorders to the TB clinical services setting in the Tomsk Oblast, Siberia, Russia, and to train TB physicians to deliver state of the art alcohol pharmacotherapy and behavioral treatments as an integrated part of routine TB care. The proposed treatment strategy could be applied elsewhere in Russia and in other settings where TB control is jeopardized by AUDs. If demonstrated to be effective, this model of integrating alcohol interventions into routine TB care has the potential for expanded applicability to other chronic co-occurring infectious and other medical conditions seen in medical care settings.

A simple and cost-effective method to prepare template DNAs for cell-free protein synthesis

The scale-up of cell-free protein synthesis reactions involves the preparation of large amounts of template DNA. While ion-exchange column chromatography methods have commonly been used to obtain purified plasmid DNA for cell-free protein synthesis reactions, these methods are costly and difficult to expand to a large scale. In this work, we report that the routine isopropyl alcohol (IPA) precipitation method can be used to prepare cell-free-expressible DNA when the co-precipitated proteins are removed. Compared to column-purification procedures, the IPA-precipitation offers obvious advantages with respect to the cost and scaling-up of template preparation, and we believe that our finding will contribute to making cell-free protein synthesis system more practical for the rapid production of preparative amounts of recombinant proteins.

Routine alcohol screening and brief interventions in general hospital in-patient wards: Acceptability and barriers

Aims: To explore the acceptability and barriers to the introduction of nurse-led routine screening and brief interventions (SBI) for alcohol misuse on general in-patient hospital wards.Methods: Screening was introduced on an in-patient ward at three general hospitals. Screening rates, numbers of referrals to alcohol liaison nurses (ALNs), brief interventions conducted and patients’ access to specialist alcohol services at follow-up were measured. Semi-structured qualitative interviews were conducted to explore staff/patient attitudes.Findings: Screening rates ranged from 17.7% to 36.6% in the three wards. The highest rates of screening and positive screening scores were recorded on a gastrointestinal (GI) ward. Attitudes of staff and patients towards the SBI process were generally positive; however, a number of current barriers to its implementation were identified.Conclusions: In order for the SBI approach to be incorporated into routine procedures in in-patient medical settings it may be necessary to provide ongoing support and training from specialist alcohol workers, and to have mechanisms that ensure the screen remains part of routine nursing documentation.

Routine alcohol screening and brief interventions in general hospital in-patient wards: Acceptability and barriers

Routine alcohol screening and brief interventions in general hospital in-patient wards: Acceptability and barriers

Botulinum Toxin Type A Injection Without Isopropyl Alcohol Antisepsis

To evaluate the infection rate after botulinum toxin type A injection without the use of isopropyl alcohol antisepsis. Isopropyl alcohol 70% solution has been used for routine skin preparation prior to botulinum toxin injection for decades; however, alcohol antisepsis does not routinely sterilize the skin, and it may not reduce the injection site infection rate. The authors performed a retrospective analysis of patients undergoing botulinum toxin type A injection without the use of isopropyl alcohol antisepsis from one surgeon from October 1999 through December 2004. Charts were reviewed for patient age, gender, indication, total number of visits, total number of needles, total number of injections, and complications attributable to infection. One hundred forty-two patients underwent botulinum toxin type A injection without isopropyl alcohol antisepsis during the study period. Patients underwent a total of 11,627 injections during the study period. Average number of visits was 6 (range, 1-25 visits). Average follow-up was 707 days (range, 7-2,165 days). No patient receiving botulinum toxin type A injection without isopropyl alcohol antisepsis sustained a local complication consistent with infection. Injection of botulinum toxin type A reconstituted with preserved saline results in an extremely low rate of infection.

Associations Between Race and Ethnicity and Receipt of Advice About Alcohol Use in the Department of Veterans Affairs

This study sought to identify racial and ethnic differences in rates of alcohol-related advice given to veterans treated in Veterans Affairs (VA) facilities. This was a cross-sectional analysis of data from the VA Survey of the Healthcare Experiences of Patients (SHEP). Participants were 255,522 veterans treated in VA ambulatory clinics in fiscal year 2005. SHEP measures included alcohol consumption questions from the Alcohol Use Disorders Identification Test and an item inquiring whether a VA clinician had given advice about drinking. Logistic regression was used to examine relationships between race and ethnicity categories and receipt of alcohol-related advice. Covariate measures included demographic characteristics and physical and mental component summary scores from the Veterans RAND Health Survey (VR-12). Among veterans who consumed any alcohol, compared with veterans from the other racial or ethnic groups, Asian, Native Hawaiian, or Pacific Islander veterans were less likely to be in the medium and highest alcohol consumption categories and non-Hispanic white veterans were less likely to be in the highest alcohol consumption category (p<.001). In a model adjusting for demographic characteristics, physical and mental health status, and alcohol consumption category, among veterans who consumed any alcohol, those who were non-Hispanic black (odds ratio [OR]=1.65, 95% confidence interval [CI]=1.47-1.84), Hispanic (OR=1.56, CI=1.35-1.80), or non-Hispanic American Indian or Alaska Native (OR=1.56, CI=1.06-2.29) were more likely to report receiving alcohol-related advice, compared with non-Hispanic white veterans. The results suggest that veterans from certain minority groups are more likely than white veterans to report receiving alcohol-related advice in the VA, after the model is adjusted for demographic characteristics, health status, and alcohol consumption. Further research is needed to understand the underlying reasons for observed differences in receipt of alcohol-related advice and the potential clinical implications.

HIV Care Providers' Implementation of Routine Alcohol Reduction Support for Their Patients

Screening and brief intervention (SBI) for alcohol reduction is an important health promoting strategy for patients with HIV, and HIV care providers are optimally situated to support their patients' reduction efforts. We report results from analyses that use data collected from providers (n = 115) in 7 hospital-based HIV care centers in the New York City metropolitan area in 2007 concerning their routine use of 11 alcohol SBI components with their patients. Providers routinely implemented 5 or more of these alcohol SBI components if they (1) had a specific caseload (and were therefore responsible for a smaller number of patients), (2) had greater exposure to information about alcohol's effect on HIV, (3) had been in their present positions for at least 1 year, and (4) had greater self efficacy to support patients' alcohol reduction efforts. Findings suggest the importance of educating all HIV care providers about both the negative impact of excessive alcohol use on patients with HIV and the importance and value of alcohol SBIs. Findings also suggest the value of promoting increased self efficacy for at least some providers in implementing alcohol SBI components, especially through targeted alcohol SBI training.

Correlates of alcohol use among methadone-maintained adults

This prospective study ( n = 190) examined correlates of alcohol use from baseline data of a longitudinal trial conducted among moderate and heavy alcohol users receiving methadone maintenance therapy (MMT). The sample included MMT clients who were 18–55 years of age, and were receiving MMT from five large methadone maintenance clinics in the Los Angeles area. Half of the sample was heavy drinkers and nearly half (46%) reported heroin use. Using a structured questionnaire, correlates of heavy alcohol use included White and Hispanic ethnicity, and fair or poor physical health combined with older age (≥50 years). We also found that MMT clients who were younger than 50 years, regardless of health status, were more likely to be heavy drinkers. Compared with moderate alcohol consumers, a greater number of heavy alcohol users also experienced recent victimization. To optimize MMT, alcohol screening should be part of routine assessment and alcohol treatment should be made available within MMT programs. Moreover, special consideration should be provided to the most vulnerable clients, such as the younger user, those with a long-term and current history of heavy drug use, and those victimized and reporting fair or poor health. In addition, promoting attention to general physical and mental health problems within MMT programs may be beneficial in enhancing health outcomes of this population.