Implementation of a family-centered treatment program for substance-abusing women and their children: barriers and resolutions

Recent federal health financing and health care delivery programs have increased access to alcohol and other drug abuse treatment programs for low-income women, and have provided intervention and prevention services for their children and families. The Village South Families in Transition (FIT) in Miami, Florida, implemented a residential treatment program for women and their children that aims to decrease alcohol and other drug use, reduce reliance on social and health welfare systems, improve functioning in specific life-skill and vocational areas, improve parenting techniques and maternal/child relations, and provide intervention and prevention services for the clients' children in a safe and supportive environment. Program implementation required resolutions to numerous barriers, including securing a facility for women and children; recruiting, hiring and training of staff; establishing and maintaining community linkages; treatment considerations; balancing treatment versus evaluation/research; and critical decisions faced by treatment staff as they modify client-centered programs to incorporate gender-specific and family-centered programs.

Sensitive detection of biotoxoids and bacterial spores using an immunomagnetic electrochemiluminescence sensor

Extremely sensitive detection of various biotoxoids and bacterial spores using the commercial ORIGEN analyzer was achieved by capture on antibody-conjugated micron sized magnetic beads (MBs) followed by binding of ruthenium (II) trisbipyridal chelate (Ru(bpy)2+3-labelled reporter antibodies. Immunomagnetically captured target materials were collected on a magnet. Electrochemiluminescence (ECL) was evoked from the Ru(bpy)3(2+)-tagged reporter antibodies by application of an electrical potential. Femtogram sensitivity levels were obtained for all biotoxoids tested including botulinus A, cholera beta subunit, ricin and staphylococcal enterotoxoid B by this immunomagnetic (IM)-ECL approach. An IM-ECL assay for Bacillus anthracis spores yielded a detection limit of at least 100 spores. The ECL signal was a function of analyte quantity over several orders of magnitude, but the immunological 'hook' effect at high antigen loads made quantitation impossible over a broader range. All assays were performed with a maximum combined incubation and assay time of approximately 40 min. This work demonstrates the extreme sensitivity of the IM-ECL approach for soluble and particulate antigens.

Self-monitoring of blood glucose in overweight type 2 diabetic patients

Self-monitoring of blood glucose (SBGM) is widely recommended for both type 1 and type 2 diabetic patients despite the lack of evidence of benefit in glucose control or as an aid in weight loss in type 2 subjects. This study tested the hypothesis that combined use of SMBG and dietary carbohydrate (CHO) counting, using the blood monitoring results to shape dietary CHO quotas, is beneficial in managing type 2 diabetes. Twenty-three overweight (body mass index, BMI 27.5-44 kg/m2) patients aged 40-75 participated in a 28-week behavioral weight control program. Baseline hemoglobin HbA1c ranged between 9.5% and 13.5% (normal range 5.5%-7.7%). Subjects were matched for weight, sex, and HbA1c and assigned to small (4-8 participants) groups which met weekly for 12 weeks and then monthly for 16 weeks. After 8 weeks, the groups were randomized either to continue the behavioral program or to have SMBG and dietary CHO counting. Glucose monitoring was performed 6 times daily (pre- and 2 h postprandially) for the first month, focusing on the meal increment and correlating this to dietary CHO intake. Weight loss was identical in both groups during the year of follow-up. The HbA1c level showed a progressive decline in experimental subjects (P < 0.05), whereas there was no improvement in control subjects.

Drug discrimination using a Pavlovian conditional discrimination paradigm in pigeons

Three pigeons were studied using a discriminated autoshaping procedure in which the presence or absence of methadone served as a conditional stimulus signalling which of two key light CSs would be followed by grain access. Drug sessions alternated randomly with no-drug sessions. Methadone (2.0 mg/kg) was administered prior to drug sessions in which a black vertical line on a white background served as CS+ and a diffuse white keylight served as CS- (reversed for bird 681). Saline or no injection was administered prior to no-drug sessions and the CS+/CS- contingencies were reversed. Discriminated performances emerged in which over 80% of the responding occurred to the appropriate stimulus. Stimulus control by methadone was assessed by presenting a range of methadone doses during 10-trial extinction sessions. A graded dose-effect curve was produced with low doses of methadone controlling saline-appropriate responding and higher doses controlling drug-appropriate responding. A range of doses of morphine, cocaine, and pentobarbital were also tested. Morphine produced methadone-appropriate responding while cocaine and pentobarbital did not.

Supporting staff health

This paper continues the theme of health at work and explains how one company set in motion a corporate health promotion programme aimed at eliminating or reducing particular disease risk factors affecting the workforce.

RNA expression of complement regulatory proteins in human brain tumors

The expression of complement regulatory proteins (CRP) on the surface of neoplastic cells has been proposed as a mechanism by which these cells evade immune surveillance. We have examined the RNA expression of the genes that encode 5 kinds of CRP in various human brain tumors to determine whether CRP expression might play a role in the malignant progression of these tumors. The benign and atypical meningiomas, and the astrocytomas showed high expression of SP-40,40, low expression of CD59, and barely detectable expression of CD46, CD55 and S-protein. The benign and atypical menigiomas showed significantly greater expression of SP-40,40 at the RNA level when compared to malignant meningiomas. This study describes the mRNA expression of meningiomas, astrocytomas, tumor cell lines and normal human tissues.

Fetal cocaine exposure and neonatal bilirubinemia

To assess the effect of fetal exposure to cocaine on neonatal serum bilirubin values, we compared 17 infants whose cocaine exposure was confirmed by urine toxicology studies, with no evidence of other drug exposure by history or urinalysis, with 31 sequentially born healthy term infants without evidence of maternal drug use. The mean (+/- SD) bilirubin concentration in control infants was 110 +/- 32 mumol/L (6.5 +/- 1.9 mg/dl) at 30.5 +/- 5.4 hours of age, compared with 55 +/- 26 mumol/L (3.2 +/- 1.5 mg/dl) at 30.8 +/- 5.3 hours in cocaine-exposed infants (p < 0.001). We also compared the abilities of cocaine and clofibrate, a known inducer of bilirubin uridine diphosphate-glucuronosyl transferase (BGT), to induce drug and bilirubin metabolizing pathways in young male Sprague-Dawley rats. Animals received drugs or saline solution for 7 days, and livers were assayed for cytochrome P-450, peroxisomal beta-oxidase, delta 5-3-ketosteroid isomerase (KSI), glutathione-S-transferase (GST), and BGT. Cocaine was a weak inducer of GST but a strong inducer of KSI, a member of the GST family of enzymes that is closely associated with bilirubin transport (ligandin) in liver, and a moderately strong inducer of BGT. Neither drug increased cytochrome P-450 levels, and only clofibrate induced peroxisomal beta-oxidase. We conclude that cocaine appears to induce bilirubin metabolizing pathways, resulting in a lower risk of neonatal hyperbilirubinemia.

A comparison of HIV risk between women and men who inject drugs

Although there is growing evidence of differences between women and men who inject drugs (IDUs) in terms of level of risk for HIV infection, very little research has been conducted specifically addressing the risk practices of women IDUs. This study formed part of a national study of HIV infection risks in IDUs and the purpose of the present analysis was an exploration of gender differences in HIV risk practices, focusing on the HIV risk practices of IDU women. 1,245 IDUs from the inner city area of Sydney took part in this study. Of these, 908 were men and 331 were women. Notable results were that female respondents were more likely to report sharing needles, they injected heroin more times in a typical using month and were more likely to have shared with someone they later found out was HIV seropositive. Female respondents also reported more sexual partners than men, were more likely to engage in prostitution, and were more likely to have sexual partners who were themselves IDUs. The results provide support for the proposition that women who inject drugs may be at greater risk of HIV infection through both their drug taking and their sexual practices. Further research is needed to explore the reasons underlying the risk practices of women who inject drugs and an understanding of these factors needs to be incorporated into HIV risk-reduction and drug harm-reduction policies and programs.

Predicting the risk of abrupt vessel closure after angioplasty in an individual patient

OBJECTIVES

We proposed to examine the relation between angiographic morphologic characteristics and abrupt closure after coronary angioplasty and to develop an empirically based risk stratification system.

BACKGROUND

Certain lesion morphologic characteristics are associated with higher rates of abrupt closure after coronary angioplasty. Previous approaches have been limited by relatively small sample sizes and an inability to combine multiple characteristics to predict risk in an individual patient.

METHODS

Lesion morphology was determined for 779 lesions in 658 patients undergoing an elective first angioplasty. Abrupt closure occurred in 63 lesions (8.1%). Variables associated with abrupt closure were identified by univariate and stepwise multiple logistic regression analysis, and internal validity was assessed by use of bootstrapping. An empirically based scoring system was developed by assigning different weights to each predictive characteristic and was then validated.

RESULTS

Almost all lesion characteristics previously labeled "adverse" were associated with an increased risk of abrupt closure, but only total occlusion, location at a branch point, increasing lesion length, evidence for thrombus and right coronary artery location were statistically significant independent predictors. Despite the large sample size, the study was underpowered to detect even a 50% increase in risk with many characteristics. Using a scoring system, we assigned each lesion a specific risk of abrupt closure. The distribution of risk was broad, with 20% of patients having < or = 2.5% risk and 25% having > 10% risk. Internal validation techniques revealed that when 10% of patients were randomly eliminated from the sample in multiple iterations, the risk estimates varied, again pointing to the need for a larger sample.

CONCLUSIONS

Empirically based weighting of lesion characteristics could quantify the risk of abrupt closure for individual patients, but a very large sample will be required to understand the interplay of complex lesion characteristics in altering expected outcomes.

Pharmacokinetics of fluconazole in cerebrospinal fluid and serum of rabbits: validation of an animal model used to measure drug concentrations in cerebrospinal fluid

Complete concentration-time data describing the pharmacokinetics of fluconazole in the cerebrospinal fluid (CSF) following a single dose are not available for humans or animals. We studied the pharmacokinetics of fluconazole with an indwelling intracisternal needle as described by R.G. Dacey and M.A. Sande (Antimicrob. Agents Chemother. 6:437-441, 1974). To determine whether the presence of an intracisternal needle alters pharmacokinetics in the CSF, we validated this model with uninfected rabbits by measuring pharmacokinetic constants following direct intracisternal and intravenous administration of fluconazole. Following direct injection, there was no alteration of elimination rates in the CSF with increasing sample number or time. Following intravenous administration, the penetration and kinetic constants were the same in individual animals from which multiple CSF samples were obtained as in a composite subject constructed by pooling virgin samples from different animals. The presence of the intracisternal needle did not alter CSF chemistry or leukocyte counts, and erythrocyte contamination was < 0.001%. While drug concentrations were measured by a microbiological assay, we also compared the sensitivity and reproducibility of a high-performance liquid chromatography (HPLC) assay with those of the microbiological assay. Following a single intravenous dose, the maximum concentration of the drug in serum, the time to maximum concentration of the drug in serum, the terminal elimination half-life in the CSF, and the percent penetration by fluconazole were 6.12 micrograms/ml, 1 h, 9.0 h, and 84.3%, respectively. We conclude that the sampling of CSF via an indwelling needle does not alter fluconazole pharmacokinetics, cause inflammation, or alter chemical parameters; that the microbiological assay is at least equivalent in sensitivity and reproducibility to the HPLC assay; and that robust parameters describing the pharmacokinetics of fluconazole are possible with this model.

Ventricular septal defect in an infant chimpanzee (Pan troglodytes)

During clinical examinations and imaging studies of a prematurely born chimpanzee, a heart murmur, tachypnea, dyspnea, and disturbances of blood flow were observed. At necropsy, cardiomegaly, ventricular hypertrophy, and septal defects confirmed the presence of congenital VSD.

High molecular weight kininogen binds to Mac-1 on neutrophils by its heavy chain (domain 3) and its light chain (domain 5)

High molecular weight kininogen (HK) binds specifically, saturably, and reversibly to neutrophils and also reciprocally inhibits the binding of fibrinogen to neutrophils. Since fibrinogen binds to the leukocyte integrin CD11b/18 (Mac-1, alpha M beta 2), we investigated whether HK bound to Mac-1 and whether the binding site was similar to that for factor X. We also examined whether one or both chains of cleaved HK (HKa) were involved. Two monoclonal antibodies, 2B5 (0.29 microM) to HK heavy chain domains 2 (D2) and 3 (D3), and C11C1 (0.26 microM) to HK light chain domain 5 (D5), inhibited by 99 and 93% the binding, respectively, of 125I-HK (8.3 nM) to neutrophils. To minimize steric hindrance, we further demonstrated that the Fab' fragments of 2B5 and C11C1 were able to inhibit the binding of this ligand to virtually the same extent as the intact antibody, indicating that, as in binding of HK to platelets and endothelial cells, both chains are involved. To directly demonstrate the involvement of each chain, we showed that the reduced alkylated light chain derived from HK and low molecular weight kininogen, which contains the same heavy chain as HK, each markedly inhibited the binding of HK to neutrophils. We localized the domain responsible for the binding in each chain by showing that recombinant D3 and D5 decreased the binding of HK to neutrophils. To define the receptor for HK, we employed three monoclonal antibodies to Mac-1: OKM1 and OKM10 to epitopes on the alpha M subunit and IB4 to an epitope on the beta 2 chain. OKM1, which can inhibit fibrinogen binding to neutrophils, inhibited HK binding by 79%, whereas the other antibodies inhibited HK binding less than 25%. Coagulation factor X also binds to Mac-1 on monocytes at a similar site to C3bi. Synthetic peptides which define noncontiguous surface loops in factor X that interact with Mac-1, failed to inhibit 125I-HK binding to neutrophils. We conclude that HK binds, via domains on its heavy chain, D3, and light chain, D5, to Mac-1 on the neutrophil surface, and HK occupies a site overlapping with fibrinogen and different from factor X.

Hemochromatosis, multiorgan hemosiderosis, and coronary artery disease

OBJECTIVE

To examine the prevalence of coronary artery disease (CAD) in autopsies of patients with iron-overload syndromes.

DESIGN

Retrospective autopsy study of CAD in cases of hemochromatosis and multiorgan hemosiderosis.

SETTING

Registry of nearly 48,000 autopsies performed at The Johns Hopkins Hospital between 1889 and 1992.

SUBJECTS

One hundred twenty-three subjects were studied. In a 2:1 control-case ratio, 82 controls matched by age, race, and sex were compared with 41 cases with iron overload.

MAIN OUTCOME MEASURE

Severity of CAD.

RESULTS

Pathological description of the coronary arteries were recorded as advanced or severe in 12% of iron-overload cases (n = 41) (mean age, 57.6 +/- 13.2 years) compared with 38% of controls (n = 82) (mean age, 57.0 +/- 13.8 years) (P = .01). The prevalence of three-vessel disease assessed by postmortem coronary arteriography was 11.1% in iron-overload cases (n = 18) (mean age, 61.7 +/- 12.2 years) compared with 33.3% in controls (n = 36) (mean age, 61.1 +/- 12.5 years) (P = .04). The odds ratio of CAD with iron overload was 0.18 (95% confidence interval, 0.04 to 0.73).

CONCLUSIONS

Iron overload resulting from hemochromatosis or multiorgan hemosiderosis is not associated with an increased prevalence of CAD.

Low-temperature spectroscopy of isolated FMO-protein and a membrane-free reaction center complex from the green sulfur bacteriumChlorobium tepidum

We have isolated the water-soluble BChla-protein (FMO-protein) from the greer sulfur bacteriumChlorobium tepidum by a new procedure involving a salt-wash of isolated membranes at alkaline pH. The absorption spectrum of the isolated FMO-protein at 77 K was compared with that of a reaction-center complex containing the FMO-protein (FMO-RC complex) isolated fromC. tepidum following the procedure of Feiler U, Nitsche W and Michel H (1992) Biochemistry 31: 2608-2614. Oxidation or illumination of the FMO-RC complex caused bleaching of a component with a maximum at 836 nm which was not present in the purified FMO-protein.

Effectiveness of early therapy with corticosteroids in Stevens-Johnson syndrome: experience with 41 cases and a hypothesis regarding pathogenesis

Evaluation of therapy for Stevens-Johnson syndrome was initiated as a retrospective analysis and then extended to a prospective series of patients treated with corticosteroids. This report extends the initial prospective study of patients with Stevens-Johnson syndrome treated with corticosteroids and evaluates the total series of 41 patients relative to outcome and the presumptive etiology. We propose that management of Stevens-Johnson syndrome requires corticosteroid therapy and that the survival of patients with Stevens-Johnson syndrome may depend on this therapy. No fatalities or adverse effects due to corticosteroids were noted. Stevens-Johnson syndrome due to a drug, a drug metabolite or viral infection may mimic a graft-versus-host reaction in which the patient rejects skin, mucous membrane, kidney or liver cells to which the drug, drug metabolite, or virus has bound. Corticosteroids suppress the inflammatory rejection until the activating agent has been eliminated.

Pathogenicity of a bovine attaching effacing Escherichia coli isolate lacking Shiga-like toxins

Escherichia coli isolate 7996-90, obtained from a calf with diarrhea, had negative results of tests for K-88, K-99, 987P, F41, CS31A, F1845, F165 or E. coli adherence factor adhesins and had negative results of tests for the toxins heat-labile, heat-stable A, heat-stable B, Shiga-like toxin (SLT)-I or SLT-II. Strain 7996-90 had localized adherence to HEp-2 cells, caused actin rearrangement in host cells to which it adhered, hybridized with the eaeA probe, and produced the 94-kd outer membrane protein associated with attaching effacing lesions. This isolate caused attaching effacing lesions in Caco-2 cell polar monolayers, rabbit intestinal loops, and the intestines of gnotobiotic pigs. The isolate belongs to serotype O26: NM and is considered a class-II attaching effacing enteropathogenic E coli. Until recent addition of more sensitive assays at veterinary diagnostic laboratories, isolates such as 7996-90 were not readily recognized as pathogens because they failed to fit into the enterohemorrhagic E coli group, members of which, be definition, produce SLT. The assays described can facilitate diagnosis of attaching effacing E coli infection when histologic evaluation is hampered by autolysis.