Injecting drug use via femoral vein puncture: preliminary findings of a point-of-care ultrasound service for opioid-dependent groin injectors in treatment

BACKGROUND

Within the UK, injecting in the femoral vein (FV), often called 'groin injecting', is a serious cause of risk and harm. This study aimed to use ultrasound scanning as a means to engage groin injectors (GIs), examine their femoral injecting sites and assess their venous health, with the intention of developing improved responses.

METHODS

Between September 2006 and March 2009, GIs attending a network of community drug treatment centres in South East England were invited to attend an ultrasound 'health-check' clinic. This paper provides a narrative account of the scanning procedure and operation of the service, with descriptive statistical analysis of GIs who attended. The analysis uses a structured, specially-developed clinical data set that incorporates a categorisation for the severity of FV damage. Case studies using ultrasound images and a link to a video are provided to illustrate the range of presentations encountered and the categorisations used for severity.

RESULTS

A total of 160 groin scans (76 bilateral and 8 unilateral) were performed in 84 GIs. The majority were men (69.0%) and the mean age of the sample was 36.8 years. The mean duration of drug use and injecting drug use was 19.7 years and 13.8 years, respectively. FV damage at the injecting site in the right groin was graded as minimal in 20 patients (25%), moderate in 27 (33.8%), severe in 16 (20.0%) and very-severe in 17 (21.3%). Corresponding figures for left FV were 24 (30.0%), 22 (27.5%), 18 (22.5%) and 16 (20.0%). Wide variation was observed in the time to the development of these grades of FV damage.

CONCLUSIONS

Modern, portable ultrasound scanners make it possible to examine the venous health of GIs in community treatment settings. Ultrasound scanning identified extensive FV damage, much hitherto-unrecognised in this population. These findings should further alert clinicians, policy-makers and patients to the urgent need for effective harm reduction responses to GI behaviour. Images of damaged FV in this paper might prove to be a useful resource for discussions about GI risks.

Associated injuries in casualties with traumatic lower extremity amputations caused by improvised explosive devices

BACKGROUND

Improvised explosive devices (IEDs) pose a significant threat to military personnel, often resulting in lower extremity amputation and pelvic injury. Immediate management is haemorrhage control and debridement, which can involve lengthy surgery. Computed tomography is necessary to delineate the extent of the injury, but it is unclear whether to perform this during or after surgery.

METHODS

The UK Joint Theatre Trauma Registry was searched to identify all UK service personnel who had a traumatic lower extremity amputation following IED injury between January 2007 and December 2010. Data were collected on injury pattern and survival.

RESULTS

There were 169 patients who sustained 278 traumatic lower extremity amputations: 69 were killed in action, 16 died from their wounds and 84 were wounded in action, but survived. The median (interquartile range) Injury Severity Score was 75 (21) for those killed in action, 46 (23) for those who died from wounds and 29 (12) for survivors. There were significantly more severe head, chest and abdominal injuries (defined as a body region Abbreviated Injury Scale score of 3 or more) in patients who were killed in action than in those reaching hospital (P < 0·001). Hindquarter amputations were the most lethal, with a mortality rate of 95 per cent. Of the 100 casualties who reached hospital alive, there were nine thoracotomies, one craniotomy and 34 laparotomies. All head or torso injuries that required immediate operation were clinically apparent on admission.

CONCLUSION

Higher levels of amputation were associated with greater injury burden and mortality. Intraoperative computed tomography had little value in identifying clinically significant covert injuries.

Narrating the social relations of initiating injecting drug use: transitions in self and society

Few studies have explored drug injectors' accounts of their initiation of others into injecting. There also lacks research on the social relations of initiating injecting drug use in transitional society. We draw upon analyses of 42 audio-recorded semi-structured interviews with current and recent injecting drug users, conducted in 2009 in the Republic of Moldova, a transitional society of south-eastern Europe. A thematic analysis informed by narrative theory was undertaken, focusing on accounts of self-initiation and the initiation of others. We also reflect upon the potential of peer efforts to dissuade would-be injectors from initiating. Findings emphasise initiation into injecting as a symbolic identity transition, enabled through everyday social relations. In turn, our analysis locates the drug transitions of the self inside an account of societal transition. We find that personal narratives of self transition are made sense of, and presented, in relation to broader narratives of social transition and change. Furthermore, we explore how narratives of self-initiation, and especially the initiation of others, serve to negotiate initiation as a moral boundary crossing. Self-initiation is located inside an account of transitioning social values. In looking back, initiation is depicted as a feature of a historically situated aberration in normative values experienced by the 'transition generation'. Accounts of the initiation of others (which a third of our sample describe) seek to qualify the act as acceptable given the circumstances. These accounts also connect the contingency of agency with broader narratives of social condition. Lastly, the power of peers to dissuade others from initiating injection was doubted, in part because most self-initiations were accomplished as a product of agency enabled by environment as well as in the face of peer attempts to dissuade.

Cessation of groin injecting behaviour among patients on oral opioid substitution treatment

AIMS

To identify factors that might influence cessation of groin injecting (GI) among patients receiving oral opioid substitution treatment (OST).

DESIGN

A cross-sectional survey.

SETTING

Drug treatment centres in South East England.

PARTICIPANTS

Groin injectors (GIs) attending an ultrasound 'health-check' clinic.

MEASUREMENTS

Clinical data and ultrasound images; comparing 65 patients who had injected drugs in the femoral vein (fv) in the previous month (current GIs) with 49 former groin injectors (former GIs).

FINDINGS

Most of the 114 clinic attendees were men (69.3%) and white European (95.6%). Mean age, duration of GI and time in treatment were 36.4 years, 54.8 months and 20.5 months, respectively. Former GIs were significantly older (P < 0.001) and had been injecting (P < 0.05) and in treatment (P < 0.05) for longer than current GIs. History of deep vein thrombosis (DVT, P < 0.05) and septicaemia (P < 0.05); moderate/severe chronic venous disease (CVD, P < 0.01); and 'very severe' fv damage on ultrasonography (P < 0.05) were more common among former GIs. A logistic regression model correcting for the effects of covariants revealed age (B 0.08; Wald 7.1; P < 0.01) and severity of venous disease (B 1.1; Wald 4.1; P < 0.05) as the strongest predictors of behaviour change.

CONCLUSIONS

GI cessation is associated with longer time in treatment, increasing age and the presence of CVD and severely damaged fv. GI appears to be an intractable behaviour that often persists despite OST and severe health complications. Persistent GI should prompt a review of whether OST is optimized and whether other interventions are needed to promote behaviour change prior to the development of serious harm.

Predictors of retention in the 'voluntary' and 'quasi-compulsory' treatment of substance dependence in europe

BACKGROUND

Policies and practices related to the quasi-compulsory treatment (QCT) of substance-dependent offenders are currently implemented in many countries, despite the absence of reliable knowledge about significant predictors of treatment retention. This study aimed to identify such predictors in QCT and voluntary treatment.

METHODS

Participants were treated in one of 65 institutions in 5 European countries. They were interviewed at intake on substance use, crimes committed, perceived pressure for treatment, self-efficacy, stage of change, employment, and health-related variables. Binary logistic regression models were computed to identify predictors of treatment retention at an 18-month follow-up. Moderator analyses were computed to investigate whether these predictors vary by treatment condition (QCT vs. voluntary).

RESULTS

A higher number of working days in the previous month was positively associated with treatment retention, while use of heroin, crack, and multiple drugs, psychiatric problems in the previous month, and lifetime depression were negatively associated with treatment retention. Higher perceived medical pressure resulted in higher treatment retention rates only for participants in QCT.

CONCLUSION

Predictors of substance abuse treatment retention are quite similar across both QCT and voluntary treatments. Perceived medical pressure is of higher relevance than the often-believed legal pressure for treatment retention in QCT.

Champions of dementia care. Interview by Jenny Knight

Bupa nurses who have had specialised training are making a difference to people with dementia.

Comparing outcomes of 'voluntary' and 'quasi-compulsory' treatment of substance dependence in Europe

AIM

This study evaluates quasi-compulsory drug treatment (QCT) arrangements for substance-dependent offenders receiving treatment instead of imprisonment in comparison to voluntary treatment within five European countries.

METHODS

Participants were interviewed with the European Addiction Severity Index, the ASI-crime module, questions on perception of pressure and self-efficacy, and the Readiness-to-Change Questionnaire at treatment entry and after 6, 12, and 18 months.

RESULTS

Reductions in substance use and crime as well as improvements in health and social integration were observed in QCT and voluntary treatment groups. After controlling for various factors, subjects in the QCT and the comparison group showed similar reductions in substance use and crime over time. Study retention was comparable in both groups.

CONCLUSION

QCT is as effective as voluntary treatment provided in the same services in reducing substance use and crime.

Epitope mapping of the human TSH receptor; structure function studies

With the aid of recombinant DNA technology (PCR/site directed mutagenesis, sequencing) the full length coding region of the human TSH receptor was manipulated to place a specific epitope peptide tag (FLAG epitope sequence) at the carboxyl end of the protein. The resulting construct was cloned into a eukaryotic expression vector and stably transfected into HeLa cells. The expression/translation of the tagged TSH receptor molecule was monitored by immune-precipitation and western blotting of protein lysates, and was found to be expressed at considerable levels using the commercially available antibodies directed towards the FLAG epitope. This analysis revealed two discrete specific bands 90-120 KDa representing, presumably, differently glycosylated forms of the receptor. TSH radio receptor assays demonstrated that the FLAG tagged TSH receptor bound TSH comparable with the wild type receptor. Furthermore TSH stimulated cAMP response in these transfected cells were comparable to the wild type receptor, thus demonstrating that the tagged receptor was functionally identical to the transfected wild type receptor. These cell lines will be of great value when analysing TSH/receptor or receptor/autoantibody interactions considering the availability of well characterized experimental anti-TSH receptor sera.

New strategy for improving dementia care in the UK

The Government’s much-anticipated national dementia strategy (Department of Health, 2009), which was launched in January, marks a significant change in the way dementia care is viewed in the UK. The Strategy sets out 17 recommendations under four themes, which have the potential to revolutionize how we care for people with dementia in the UK. The four key themes are:

Distributing foil from needle and syringe programmes (NSPs) to promote transitions from heroin injecting to chasing: an evaluation

Background

The report presents evaluation results from an intervention using specially produced foil packs to promote a transition from heroin injecting to inhalation (chasing) with injecting drug users (IDUs) attending four needle and syringe programmes (NSPs) in south west England.

Methods

Service activity/uptake measures, brief structured interviews.

Results

Out of 320 attenders, 54% took the foil packs when they became available. Over the period of the evaluation, NSP transactions increased by 32.5% from 1,672 to 2,216. Additionally, 32 new clients (non-injecting heroin users) started attending the service to obtain the foil packs. This group would not otherwise have been in contact with the treatment service. More detailed data from one site are reported for 48 recent injectors who took foil within the NSP where the piloting first commenced. Prior to the introduction of the foil packs, 46% of this sub-group reported chasing heroin in the previous four weeks. At follow up, 85% reported using the foil to chase heroin on occasions when they would otherwise have injected. Among the people who took it, client satisfaction with the quality and size of the foil packs was good and respondents viewed its availability as a valuable extension to the NSP's services.

Conclusion

These findings suggest that distributing foil packs can be a useful means of engaging NSP attenders in discussions about ways of reducing injecting risks and can reduce injecting in settings where there is a pre-existing culture of heroin chasing. Further research should see whether these findings can be reproduced in other cultural contexts and evaluate whether the observed behavioural changes are sustained and lead to reductions in harm including blood-borne infections and overdose.

Early exit: estimating and explaining early exit from drug treatment

Background

Early exit (drop-out) from drug treatment can mean that drug users do not derive the full benefits that treatment potentially offers. Additionally, it may mean that scarce treatment resources are used inefficiently. Understanding the factors that lead to early exit from treatment should enable services to operate more effectively and better reduce drug related harm. To date, few studies have focused on drop-out during the initial, engagement phase of treatment. This paper describes a mixed method study of early exit from English drug treatment services.

Methods

Quantitative data (n = 2,624) was derived from three English drug action team areas; two metropolitan and one provincial. Hierarchical linear modelling (HLM) was used to investigate predictors of early-exit while controlling for differences between agencies. Qualitative interviews were conducted with 53 ex-clients and 16 members of staff from 10 agencies in these areas to explore their perspectives on early exit, its determinants and, how services could be improved.

Results

Almost a quarter of the quantitative sample (24.5%) dropped out between assessment and 30 days in treatment. Predictors of early exit were: being younger; being homeless; and not being a current injector. Age and injection status were both consistently associated with exit between assessment and treatment entry. Those who were not in substitution treatment were significantly more likely to leave treatment at this stage. There were substantial variations between agencies, which point to the importance of system factors. Qualitative analysis identified several potential ways to improve services. Perceived problems included: opening hours; the service setting; under-utilisation of motivational enhancement techniques; lack of clarity about expectations; lengthy, repetitive assessment procedures; constrained treatment choices; low initial dosing of opioid substitution treatment; and the routine requirement of supervised consumption of methadone.

Conclusion

Early exit diminishes the contribution that treatment may make to the reduction of drug related harm. This paper identifies characteristics of people most likely to drop out of treatment prematurely in English drug treatment services and highlights a range of possibilities for improving services.

Traumatic axonal damage in the brain can be detected using beta-APP immunohistochemistry within 35 min after head injury to human adults

Immunohistochemistry staining for beta-amyloid precursor protein (beta-APP) is a sensitive method to detect early axonal damage in traumatic brain injury, which was previously estimated to be of minimum 60-90 min after head injury. We present seven cases of well-documented posttraumatic survival of 35-60 min where beta-APP detects early axonal damage. Cases were selected from routine work where documentation about survival is judged to be accurate. These are divided into three groups: group 1: severe head injury (n = 7) with documented survival between 35 and 60 min. Group 2: severe head injury (n = 4) with documented survival of less than 30 min. Group 3: cases (n = 4) where death was not due to head injury but survival is documented between 45 and 109 min. The brains were fixed in formalin for 4 weeks and six regions (frontal lobe with anterior corpus callosum, parietal lobe with deep white matter, basal ganglia with posterior limb of internal capsule, cerebellum with white matter and middle cerebellar peduncle and pons with basis pontis and superior cerebellar peduncle) were sampled. All blocks were stained for haematoxylin and eosin and beta-APP and selected ones for CD68, using antigen retrieval method. In group 1 sections revealed beta-APP immunoreactivity in forms of small globules and granules and occasionally as thin and short filaments. These were detected in the pons, corpus callosum, internal capsule and cerebral white matter, with some variation in localization and intensity. In groups 2 and 3 all the sections were negative for beta-APP staining. None of the cases showed evidence of severe brain swelling, increased intracranial pressure, ischaemia or infection. Using the antigen retrieval method, beta-APP immunohistochemistry can detect axonal damage within 35 min after severe head injury. These results may have an implication in the consideration of minimal survival time after traumatic head injury in medico-legal practice.

London audit of drug-related overdose deaths: characteristics and typology, and implications for prevention and monitoring

OBJECTIVES

To describe the circumstances and draft a typology of drug-related overdose deaths.

SETTING

London, 2003.

METHODS

An audit of 148 drug overdose deaths (involving heroin, methadone, dihydrocodeine, cocaine, amphetamine or MDMA) investigated by coroners during 2003. Information extracted on toxicology, pathology and circumstances were used to identify drug(s) implicated in the death.

RESULTS

Poly- or multiple drug use was detected in the majority of deaths with at least 69 different combinations, including 66% for heroin and 42% for cocaine. Six categories of death were identified involving an opiate (100, 68%); cocaine (14, 9%); other controlled drug (five, 3%); mixed drug overdose (18, 12%); other prescribed drug (five, 3%); and other causes (seven, 5%). A witness was present and the death was not instantaneous in 92 (61%) cases, although evidence in the coronial file suggested that in the majority of cases the overdose went unnoticed until too late to intervene. In all, 15 (one in 10) of the deceased were released from prison within 3 months of death; and 37 (one in four) were reported as in receipt of a methadone prescription.

CONCLUSIONS

Perhaps for the first time in the United Kingdom cocaine was detected in more drug overdose deaths than methadone. However, reducing heroin use is central to the prevention of drug-related deaths. We recommend that overdose prevention encompasses strategies to encourage a 'mutual duty of care' among problem drug users, and in the United Kingdom further investigation of the relationship of methadone treatment failures on overall trends in drug-related deaths is merited.

Drug consumption rooms: an overdue extension to harm reduction policy in the UK?

This commentary examines the drug policy context of drug consumption rooms (DCRs) in the UK and describe the conclusions of an Independent Working Group (IWG) that was set up to evaluate the evidence of need in the UK, the international evaluation literature and legal, political and ethical concerns. Having considered this evidence, the IWG produced its report in May 2006, recommending a trial of DCRs in the UK, on the basis that DCRs offer a unique and promising way to work with problematic drug users in order to reduce the risk of overdose, improve their health and lessen the damage and costs to society. However, despite support for the idea from a number of quarters, the UK Government has rejected this recommendation, citing previously deployed arguments that do not appear to be carry much weight in 2007.

5-Year trends in use of hallucinogens and other adjunct drugs among UK dance drug users

AIMS

To describe and assess trends in the use of hallucinogens and other adjunct drugs over a 5-year period.

DESIGN

Repeated-measures cross-sectional survey.

SETTING AND PARTICIPANTS

Annual magazine-based survey targeting people who use drugs in dance contexts.

MEASUREMENTS

Lifetime use prevalence (ever used); age of first use; current use prevalence (any use within the last month), and extent of use within the last month (number of days used) for LSD, psilocybin, ketamine, GHB and nitrates.

FINDINGS

Prevalence increases for psilocybin, ketamine, GHB and nitrates use have been detected, with a sharp recent rise in current psilocybin use in 2002-2003 contrasting with more gradual and comprehensive evidence of increased ketamine use throughout the period 1999-2003. The declining prevalence of LSD use in general population surveys is replicated in this sentinel population study.

CONCLUSIONS

The rise in prevalence of hallucinogen and other adjunct drugs identified among dance drug users may be mirrored by wider prevalence increases among young people with a consequent need to study these trends carefully and to develop effective interventions, where required.

Setting the backdrop in caring for people with dementia

Dementia affects one in 20 people aged between 70 and 79 years in the UK. The prevalence increases to one in five as people reach their 80s and there are a further 18,000 people with dementia under the age of 65. Add to this the thousands of carers and healthcare staff supporting those living with dementia and it is hard to believe that only now have guidelines been released to look at every aspect of dementia care.

Cultured skin fibroblast cells derived from bluetongue virus-inoculated sheep and field-infected cattle are not a source of late and protracted recoverable virus

A recent hypothesis to explain the recurrence of bluetongue disease after winter seasonal absences of the vector has suggested a role for persistent infection of sheep. This report presents combined independent work from two laboratories investigating the possible recovery of Bluetongue virus (BTV) over a protracted period after infection of both sheep and cattle. Prior to infection with either cell-culture-adapted or non-culture-adapted BTV, sheep were subjected to a preliminary exposure to Culicoides sp. insects, which reportedly facilitates recovery of virus from infected sheep several months post-infection (p.i.). A series of skin biopsies at different intervals p.i. was used to establish skin fibroblast (SF) cultures from which attempts were made to detect virus by isolation and by molecular and immunological methods. Also examined was the effect on virus recovery of additional exposure to Culicoides sp. prior to skin biopsy during the post-inoculation period. A herd of cattle sentinels for surveillance of natural BTV infection in northern Australia was monitored prospectively for seroconversion. Evidence of infection initiated attempted virus recovery by establishing SF cultures. It was found that in both cattle and sheep there was not a protracted period over which BTV could be recovered from SF cultures. The data do not support a general hypothesis that BTV persists in either sheep or cattle.

New clinical guidance to support patients with dementia

NICE and the Social Care Institute for Excellence have issued guidance to help health and social care professionals support the 750,000 people in the UK who have dementia and their carers. The guidance addresses the full range of treatments and services for people. This article outlines how professionals can work to ensure the recommendations are successfully implemented.

Synovial shelves of the knee: association with chondral lesions

The objectives of the present study were to evaluate whether synovial shelves of the knee are associated with increased incidence of chondral lesions and to determine which types of plica are associated with significant articular damage. Data were collected prospectively from 1,000 consecutive knee arthroscopies. Of these patients, 321 (32.1%) were found to have synovial shelves of the knee. Patients details (age, sex, duration of symptoms, injuries, and possible mechanism of injury), operative details (types and number of portals, equipment used), intra-articular findings (articular, meniscal and synovial lesions, and stability characteristics) and procedures performed were recorded on a special database. Synovial shelves of the knee were recorded using a modification of the Sakakibara classification. Articular lesions were noted on anatomic articular maps of the different functional zones using a functional zoning system that presaged the current ICRS system. An increased incidence of articular lesions was found in patients with synovial shelves, in comparison with patients without shelves (94.7 vs. 81% respectively; P < 0.001). Patients with larger and more fibrotic shelves were found to have increased incidence of cartilage lesions, in comparison with patients with type smaller and less fibrotic shelves (96.5 vs. 86.4%, respectively; P = 0.002), as well as cartilage lesions with bigger size (84 vs. 71.4%, respectively; P = 0.02). Patella (P < 0.001), and specific areas (P < 0.001) of the medial femoral condyle, were areas with increased incidence of cartilage lesions, in patients with synovial shelves. In conclusion, synovial shelves of the knee are associated with an increased incidence of cartilage lesions. Larger shelves, particularly with chronic inflammation are associated with more frequently occurring and larger articular lesions. Areas with increased incidence of chondral lesions, in patients with plicae, include particularly the lower patella and the non-weight-bearing medial femoral condyle.

The rise of Viagra among British illicit drug users: 5-year survey data

Viagra use among British nightclubbers, a sentinel population of illicit drug users, was first reported in 1999. There has since been little attention paid to the evolution of patterns of non-prescribed use, apart from among men who have sex with men. Beginning in 1999 an annual survey has been conducted with a specialist dance music magazine, permitting cross-sectional comparisons over time. Rising levels of lifetime and current use prevalence and data on patterns of both male and female use are reported, along with elevated prevalence levels among both gay men and women. Experimentation with Viagra appears increasingly to have become established among British nightclubbers who use recreational drugs. Ethnographic and epidemiological study and monitoring of adverse consequences is now needed to fully appreciate reasons for use and the extent of possible harms.

An evaluation of a brief motivational intervention among young ecstasy and cocaine users: no effect on substance and alcohol use outcomes

AIMS

To investigate whether a stimulant- and alcohol-focused brief motivational intervention induces positive behaviour change among young, regular users of MDMA ('ecstasy'), cocaine powder and crack cocaine.

DESIGN AND MEASUREMENTS

A randomized trial of the intervention versus a control group who received written health risk information materials only. All participants completed a baseline self-assessment questionnaire before randomization. Outcome measures were self-reported period prevalence abstinence from ecstasy, cocaine powder and crack cocaine and the frequency and amount of stimulant and alcohol use in the previous 90 days, recorded at 6-month follow-up via self-completion questionnaire and personal interview.

PARTICIPANTS AND SETTING

A total of 342 adolescent and young adult stimulant users (aged 16-22 years) were recruited and 87% were followed-up. The intervention was delivered by a team of 12 agency youth drug workers and two researchers at five locations in Greater London and south-east England.

FINDINGS

There were no significant differences in abstinence for ecstasy, cocaine powder or crack cocaine use between the experimental and control groups. Contrasting follow-up with baseline self-reports, there were no between-group effects for changes in the frequency or amount of stimulant or alcohol use. Participant follow-up data suggested that the baseline assessment was a contributing factor in within-group behaviour change among experimental and control condition participants.

CONCLUSIONS

Our brief motivational intervention was no more effective at inducing behaviour change than the provision of information alone. We hypothesize that research recruitment, baseline self-assessment and contact with study personnel are influences that induce positive reactive effects on stimulant use.

Falklands War veterans' perceptions of social support and the reconciliation of traumatic memories

The current paper focused on the role social support plays in the reconciliation of traumatic memories. Four currently serving, male Royal Marines ranging from 40-42 years participated in semi-structured one-to-one interviews that explored perceptions of social support. Using thematic analysis, comradeship was found to be important in terms of maintaining support networks. However, this resource was used to avoid the reconciliation of traumatic memories. Social support from family members was sought when veterans were reassured that relatives would understand their experiences, and could support reconciliation. The importance of positive societal reaction was also emphasized. The paper concludes by highlighting the potential for early life reconciliation of traumatic war memories through the creation of a meaningful personal narrative.

Calorie restriction induces mitochondrial biogenesis and bioenergetic efficiency

Age-related accumulation of cellular damage and death has been linked to oxidative stress. Calorie restriction (CR) is the most robust, nongenetic intervention that increases lifespan and reduces the rate of aging in a variety of species. Mechanisms responsible for the antiaging effects of CR remain uncertain, but reduction of oxidative stress within mitochondria remains a major focus of research. CR is hypothesized to decrease mitochondrial electron flow and proton leaks to attenuate damage caused by reactive oxygen species. We have focused our research on a related, but different, antiaging mechanism of CR. Specifically, using both in vivo and in vitro analyses, we report that CR reduces oxidative stress at the same time that it stimulates the proliferation of mitochondria through a peroxisome proliferation-activated receptor coactivator 1 alpha signaling pathway. Moreover, mitochondria under CR conditions show less oxygen consumption, reduce membrane potential, and generate less reactive oxygen species than controls, but remarkably they are able to maintain their critical ATP production. In effect, CR can induce a peroxisome proliferation-activated receptor coactivator 1 alpha-dependent increase in mitochondria capable of efficient and balanced bioenergetics to reduce oxidative stress and attenuate age-dependent endogenous oxidative damage.

Current management of bipolar affective disorder: is it reflective of the BAP guidelines?

In October 2003 the British Association of Psychopharmacology (BAP) published evidence-based guidelines on the management of bipolar disorder. The aim of this study was to assess whether the guidelines could provide the basis for examining clinical decisions and the extent to which practice accords with these guidelines. Case notes of out patients with bipolar disorder were reviewed. Demographic details, and treatment recommendations were determined. The management of affective episodes was evaluated and compared with BAP guidelines. In 84 subjects, 224 affective episodes were identified. Treatment was consistent with BAP guidelines in 72% of episodes. Mania was more likely to be managed in accordance with guidelines than depression or mixed episodes. The use of antidepressant medication was the most likely intervention to deviate from recommendations. Reasons for treatments at odds with the guidelines were identified. Our study demonstrates that clinical practice among a range of psychiatrists broadly reflects the guidelines that have been issued by the British Association of Psychopharmacology (BAP). The BAP guidelines offer a practical and auditable basis for the short- and long-term treatment of bipolar affective disorder.

The relationship between legal status, perceived pressure and motivation in treatment for drug dependence: results from a European study of Quasi-Compulsory Treatment

This paper reports on intake data from Quasi-Compulsory Treatment in Europe, a study of quasi-compulsory treatment (QCT) for drug dependent offenders. It explores the link between formal legal coercion, perceived pressure to be in treatment and motivation amongst a sample of 845 people who entered treatment for drug dependence in five European countries, half of them in quasi-compulsory treatment and half 'voluntarily'. Using both quantitative and qualitative data, it suggests that those who enter treatment under QCT do perceive greater pressure to be in treatment, but that this does not necessarily lead to higher or lower motivation than 'volunteers'. Many drug-dependent offenders value QCT as an opportunity to get treatment. Motivation is mutable and can be developed or diminished by the quality of support and services offered to drug-dependent offenders.

Is there an association between articular cartilage changes and degenerative meniscus tears?

PURPOSE

The objective of the present study was to evaluate whether horizontal cleavage and complex meniscus tears, which are degenerative tears, are associated with an increased incidence of cartilage damage, in comparison with patients having other patterns of meniscal injury.

TYPE OF STUDY

Case series study.

METHODS

Data were collected prospectively from 497 consecutive knee arthroscopies carried out from 1997 to 2001. Patient data (age, sex, duration of symptoms, injuries, and possible mechanism of injury), operative details (types and number of portals, equipment used), intra-articular findings (articular, meniscal and synovial lesions, and stability characteristics), and procedures performed were recorded. Articular lesions were noted on anatomic articular maps of the different functional zones using a system that presaged the current Internal Cartilage Repair Society system.

RESULTS

A comparison of patients with horizontal cleavage and complex meniscal tears to patients with other types of meniscal tear showed for the former (1) increased incidence of chondral lesions (88.4% v 69.6%, respectively, P < .001), (2) increased severity--type III and IV Outerbridge classification--of chondral lesions (52.8% v 29.4%, respectively, P < .001), and (3) increased incidence of patients having more than 1 chondral lesion (65.3% v 33%, respectively, P < .001).

CONCLUSIONS

Complex and horizontal cleavage meniscal tears are highly associated with an increased incidence and severity of cartilage degeneration compared with other types of meniscal tears. Degenerative meniscus tears are not as benign as was previously thought. New age-related categories of chondral damage are emerging.

LEVEL OF EVIDENCE

Level IV, case series prognostic study.

Coercing change: balancing rights, justice and health

Britain is undergoing its biggest change in drug policy and practice ever — and most of it without a shred of evidence to back it up. Despite mountains of evidence that community treatment works, criminal interventions, such as DTTOs, are still being extended, expanded and re‐invented across the UK — at huge cost to the UK taxpayer and at the expense of other forms of treatment. Neil Hunt is part of a pan‐European research study looking at coercive treatment within the criminal justice system. We reveal what the government is not telling us about their crime agenda.

Nitrogen and phosphorus removal from plant nursery runoff in vegetated and unvegetated subsurface flow wetlands

Subsurface horizontal flow reed beds are being evaluated for Nitrogen (N) and Phosphorus (P) removal from plant nursery runoff water in New South Wales Australia. The need to include plants (Phragmites australis), the effect of reaction time (3.5 v 7.0 d) and dissolved organic carbon (DOC) on N and P removal in batch fed gravel wetland tubs (55 L) was studied over 19 months. Simulated nursery runoff water containing N (10.1 mg L(-1), 74% as NO3) and P (0.58 mg L(-1), 88% as PO4) and DOC (2-5 mg L(-1)) was used. The planted wetland tubs removed >96% TN and TP over most of the 19-month study period while unplanted tubs were inefficient (<16% N and <45% P removal) and occasionally discharged nutrients. Doubling the reaction time to 7.0 days had no effect on nutrient removal. Plant nutrient uptake accounted for most of the N (76%) and P (86%) removed while roots and rhizomes were the dominant sink (N 58%, P 67%). The addition of methanol (C:N-3:1) to unplanted tubs achieved 81-98% N removal. In Carbon limited low nutrient nursery runoff, plants were essential to a gravel-based wetland to achieve efficient nutrient removal with effluent TN and TP concentrations of <1 mg L(-1) and 0.05 mg L(-1), respectively with a 3.5 day reaction time.

Five-year trends in patterns of drug use among people who use stimulants in dance contexts in the United Kingdom

AIMS

To describe and evaluate trends in the use of stimulant drugs over a 5-year period using an under-studied data collection method.

DESIGN

Repeated-measures cross-sectional survey.

SETTING AND PARTICIPANTS

Annual magazine-based survey targeting people who use stimulant drugs in dance contexts.

MEASUREMENTS

Life-time use prevalence (ever used), age of first use, current use prevalence (any use within the last month) and extent of use within the last month (number of days used) for a range of stimulant drugs. Additional measures of quantity of ecstasy used were also collected.

FINDINGS

Trends in life-time and current prevalence over time have been detected and comparisons made between different stimulant drugs. Evidence is obtained of broad stability in patterns of stimulant use in respect of age of first use and frequency of use among ongoing users. Despite an apparent reduction in the current prevalence of ecstasy use, the proportion of heavy users (usually >4 pills per session) has more than doubled between 1999 and 2003.

CONCLUSIONS

This purposively sampled population study has yielded time trend data broadly consistent with other indicators, where they exist, and also has demonstrable potential to identify new drug trends. Further comparisons of purposive samples and randomly formed samples are needed.

Genetic basis of erythromycin resistance in oral bacteria

We determined the prevalence of erythromycin-resistant bacteria in the oral cavity and identified mef and erm(B) as the most common resistance determinants. In addition, we demonstrate the genetic linkage, on various Tn1545-like conjugative transposons, between erythromycin and tetracycline resistance in a number of isolates.

Fibre mapping – a case study

Fibre mapping, more commonly known as one-to-one taping, was developed in Germany approximately twenty years ago. The technique facilitates the distribution of fibres on a surface to be recorded. The impact of this technique on the investigation of serious crime has been reported in the European Fibre Group on several occasions. This paper represents a case study of the application of the technique. It is believed to be the first time that this technique has been successfully applied in the United Kingdom.

An easy and accurate preoperative method for determining tibial nail lengths

Estimating the correct nail length for solid tibial nails can be problematic. Most techniques reported in the literature for determining tibial nail length are not accurate. In a retrospective study of 16 patients in our unit, only three had ideal nail sizes. In these patients, as part of phase I of our study, we measured their normal leg's length from knee joint line to ankle joint line. An ideal nail length for each of these patients was estimated from a whole length radiograph of the nailed tibia. Comparing these two data, we found that deducting 20 mm from the leg measurement gave appropriate nail lengths. We also compared this with three other anthropometric measurements; tibial tuberosity to medial malleolus, joint line to medial malleolus and olecranon to head of V metacarpal head distance. The joint line to joint line measurement was the most reliable and showed the best correlation with ideal nail lengths (0.982). In phase II, a prospective study on 15 patients, we used the joint line to joint line measurement to determine nail sizes. A postoperative review of the radiographs showed all the nails to be of adequate length. This strengthened the fact that the joint line to joint line measurement is the most accurate and easy method to determine tibial nail lengths.

Novel tetracycline resistance determinant from the oral metagenome

A major drawback of most studies on how bacteria become resistant to antibiotics is that they concentrate mainly on bacteria that can be cultivated in the laboratory. In the present study, we cloned part of the oral metagenome and isolated a novel tetracycline resistance gene, tet(37), which inactivates tetracycline.

Prevalence of tetracycline resistance genes in oral bacteria

Tetracycline is a broad-spectrum antibiotic used in humans, animals, and aquaculture; therefore, many bacteria from different ecosystems are exposed to this antibiotic. In order to determine the genetic basis for resistance to tetracycline in bacteria from the oral cavity, saliva and dental plaque samples were obtained from 20 healthy adults who had not taken antibiotics during the previous 3 months. The samples were screened for the presence of bacteria resistant to tetracycline, and the tetracycline resistance genes in these isolates were identified by multiplex PCR and DNA sequencing. Tetracycline-resistant bacteria constituted an average of 11% of the total cultivable oral microflora. A representative 105 tetracycline-resistant isolates from the 20 samples were investigated; most of the isolates carried tetracycline resistance genes encoding a ribosomal protection protein. The most common tet gene identified was tet(M), which was found in 79% of all the isolates. The second most common gene identified was tet(W), which was found in 21% of all the isolates, followed by tet(O) and tet(Q) (10.5 and 9.5% of the isolates, respectively) and then tet(S) (2.8% of the isolates). Tetracycline resistance genes encoding an efflux protein were detected in 4.8% of all the tetracycline-resistant isolates; 2.8% of the isolates had tet(L) and 1% carried tet(A) and tet(K) each. The results have shown that a variety of tetracycline resistance genes are present in the oral microflora of healthy adults. This is the first report of tet(W) in oral bacteria and the first report to show that tet(O), tet(Q), tet(A), and tet(S) can be found in some oral species.