Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments

STUDY OBJECTIVE

Chest pain and myocardial infarction following the use of cocaine have been well documented. We assessed the prevalence of cocaine use in patients who presented to the emergency department with chest pain of possibly ischemic origin.

DESIGN

During times of research assistant availability, consecutive adults with the chief complaint of chest pain unexplained by trauma or radiographic abnormality were questioned about cocaine use in the preceding week. Urine was tested for the presence of cocaine or cocaine metabolites with a highly accurate bedside urine test kit (specificity, 100%; sensitivity 98%). Anonymous unlinked data-collection methods were used. Therefore we could not determine whether the patients who used cocaine had sustained myocardial infarctions.

SETTING

One suburban and three urban EDs.

RESULTS

We enrolled 359 patients with a mean age of 51 years, 8% of whom sustained myocardial infarctions. Sixty patients (17%) had cocaine or cocaine metabolites in urine. The likelihood of testing positive for cocaine varied by age group: 18 to 30 years, 29%; 31 to 40 years, 48%; 41 to 50 years, 18%; 51 to 60 years, 3%; 61 years or older, 0% (P < .0001). Of the 60 patients who tested positive for cocaine, only 43 (72%) admitted recent use.

CONCLUSION

Many ED patients with chest pain have recently used cocaine. Because the recent use of cocaine is not uncommon in patients with chest pain up to 60 years old, such patients should be questioned about cocaine use. When treatment or disposition may be altered, consideration should be given to objective assessment of cocaine use because patient self-report does not appear reliable.

Attitudes towards people with HIV: are they as stigmatizing as people with HIV perceive them to be?

Stigma is a feature of HIV disease and many people who are HIV-positive report that their lives are affected by fear of discrimination (felt stigma). Although opinions do not necessarily predict behaviour, this article examines whether the public's avowed attitudes to people with HIV are as punitive and stigmatizing as those infected think they are, and the extent to which public attitudes may contribute to felt stigma. A street survey was conducted in Glasgow and Edinburgh, Scotland, asking a stratified quota sample of 300 men and women of all ages to complete a short questionnaire about their attitudes toward people with HIV. The same questionnaire was also completed by 42 men and women with HIV. One in five respondents in the street survey, and all of those with HIV, were also asked to complete the questionnaire imagining that they were a typical member of the public, to find out whether both groups attributed more hostile attitudes to generalized others than they themselves professed. Overall, the general public had relatively liberal views about people with HIV although a majority felt that some restrictions should be placed upon their freedom. Controlling for age, sex, socioeconomic status and city, people with HIV had more liberal attitudes than the general public, but perceived public attitudes to be far less liberal than were reported in the street survey. Respondents in the street survey also perceived generalized others to be less liberal than themselves. These results provide evidence of felt stigma among people with HIV and the policy implications are discussed. The findings are also set within a theoretical framework concerning the nature of attitudes, their relationship to behaviours, and the pervasiveness of negative images associated with AIDS.

Unconventional conceptions and HIV

The condom is widely recommended as the principal method for preventing HIV transmission, but such advice obviously does not apply to women who are seeking to become pregnant. In this sense, 'safer sex' is incompatible with reproduction. Existing research into HIV transmission has examined the choices made by those wishing to conceive within a sexual relationship; such research shows that HIV is not a highly significant factor in their decision-making processes. This study aims to extend the debate by exploring the decision-making processes of women seeking to become pregnant with donated sperm. In particular, we focus on women outside the fertility clinic system who do not have access to sperm screened for HIV to see whether HIV is a significant factor in these women's decisions. The study involved in-depth interviews with 20 women (14 lesbians, one bisexual and five heterosexuals) recruited through informal networking and snowball sampling. HIV was a salient concern for our sample, largely because of their contacts with gay men, but nonetheless most of these women took some risks. On the one hand, the conscious deliberations necessary to conceive through self-insemination facilitated risk reduction, as did factors such as 'stranger-danger'. On the other hand, factors such as the scarcity of suitable sperm donors and the women's own feelings of gratitude and loyalty to their donors mitigated against their requesting that their donor take an HIV test. This study highlights the need to provide information for women seeking self-insemination, and to remove restrictions on access to fertility clinics, in order to reduce their risk of HIV infection and subsequent vertical transmission.

Dentists' attitudes toward the treatment of HIV-positive patients

The authors studied the attitudes of 1,000 U.S. dentists toward the treatment of HIV-positive patients. Using a random-sample mail survey, they measured dentists' professional attitudes toward treating HIV/AIDS patients, fear of contagion and negative emotions toward HIV-positive patients. The results indicate that 68 percent of the respondents would treat an HIV-positive patient, even if the possibility for a legitimate referral exists.

The reproductive careers of a cohort of men and women following an HIV-positive diagnosis

This report examines the consequences of a positive HIV diagnosis upon the reproductive decision-making of 39 men and women in Scotland. Whilst the majority initially decide never to have any (more) children this sometimes changes as other factors gain ascendancy, such as a partner wanting 'their' child and about one-third had had a child or were intending to do so. The motivations underlying such decisions are discussed and ways in which health services could intervene to support people with HIV in making reproductive choices and to minimise the risk of transmission to an HIV-negative partner and the child are suggested.

Differential effects of oral glucose-mediated versus intravenous hyperinsulinemia on circulating androgen levels in women

OBJECTIVE

To determine whether transient endogenous or continuous exogenous hyperinsulinemia produced different changes in circulating gonadal steroid levels because insulin is a putative regulator of gonadal steroid secretion in polycystic ovarian syndrome (PCOS).

DESIGN

An oral glucose tolerance test (OGTT) and a 2-hour euglycemic clamp (+100 microU/mL [718 pmol/L] steady-state insulin levels) were performed in obese patients with PCOS (n = 7) in nonobese patients with PCOS (n = 5), and in age- and weight-matched ovulating normal women (obese normal n = 7, nonobese normal n = 6).

RESULTS

Despite increased insulin levels, the levels of T and androstenedione (A) decreased in three of the four groups during the OGTT (nonobese normal women showed a slight increase in T during the OGTT). In contrast, the continuous 2-hour insulin infusion resulted in increased androgen levels. When all four groups were pooled, the difference in the changes in A levels between the two tests was significant, and the difference in T levels between the two tests approached significance.

CONCLUSIONS

Transient physiological hyperinsulinemia produced by an oral glucose load was associated with a decrease rather than an increase in circulating androgen levels. The effects on circulating androgen levels of oral glucose-mediated increases in insulin levels were significantly different from those of a continuous intravenous insulin infusion. Sustained hyperinsulinemia produced by exogenous insulin infusion appeared to be required to increase androgen levels in women; transient physiological increases in insulin levels after an oral glucose load were insufficient to produce hyperandrogenism. Postmeal hyperinsulinemia does not contribute to hyperandrogenism in women.

Nausea: the most important factor determining length of stay after ambulatory anaesthesia. A comparative study of isoflurane and/or propofol techniques

Speed of recovery and length of stay in hospital were studied in 95 ambulatory patients undergoing laparoscopy or arthroscopy. The patients were divided into three groups regarding maintenance of anaesthesia. Group A (n = 32) received isoflurane 0.7% end-tidally, group B (n = 31) propofol infusion for 25 min and thereafter isoflurane, and group C (n = 32) received an infusion of propofol throughout the procedure. Recovery was assessed by a combination of the Maddox-Wing, the Choice Reaction Time test and p-deletion. The awakening period was somewhat shorter in group A, but psychomotor recovery was somewhat slower compared to groups B and C. The length of stay in hospital depended on whether the patient was nauseated or not. In group A, 44% suffered from nausea requiring medical intervention compared to 13% and 19% in groups B and C, respectively. The stay in hospital was 235 +/- 90 min (mean +/- standard deviation) in group A compared to 184 +/- 56 min and 197 +/- 55 min in groups B and C, respectively. The non-nauseated patients in group A had a stay in hospital of 188 +/- 55 min compared to 184 +/- 52 and 184 +/- 37 in the non-nauseated patients in groups B and C, respectively. In total, the nauseated patients (n = 24) stayed 267 +/- 95 min compared to 185 +/- 47 min for the non-nauseated patients (n = 71), P < 0.001. We found nausea to be the most important factor determining length of stay after ambulatory anaesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Ethnicity and polycystic ovary syndrome are associated with independent and additive decreases in insulin action in Caribbean-Hispanic women

This study was conducted to determine the impact of polycystic ovary syndrome and ethnicity on insulin action. Thirteen Caribbean-Hispanic and 10 non-Hispanic white polycystic ovary syndrome women were compared with 5 Caribbean-Hispanic and 8 non-Hispanic white normal women matched for age, weight, and body composition. All subjects underwent a 2-h 75 g oral glucose tolerance test and euglycemic glucose clamp study with a 40 mU.m-2 x min-1 insulin dose. Hepatic glucose production was determined basally and throughout the euglycemic clamp study. Polycystic ovary syndrome was associated with significant increases in fasting insulin levels (P < 0.05) and in 2-h postglucose-load glucose and insulin levels (P < 0.001). Ethnicity was not associated with any changes in these parameters. Polycystic ovary syndrome but not ethnicity was also associated with hepatic insulin resistance, because significant (P < 0.05) residual hepatic glucose production occurred during the euglycemic clamp in the polycystic ovary syndrome women. However, significant independent effects existed for both polycystic ovary syndrome (P < 0.01) and ethnicity (P < 0.05) that resulted in decreased insulin-mediated glucose disposal. Similarly, significant independent effects of polycystic ovary syndrome (P < 0.005) and ethnicity (P < 0.05) occurred, resulting in increased steady-state insulin levels during the euglycemic clamp. This appeared to be, in part, secondary to a decrease in the metabolic clearance rate of insulin associated with ethnicity (P < 0.05). We conclude that polycystic ovary syndrome and ethnicity result in independent and additive decreases in insulin sensitivity in Caribbean-Hispanic women.(ABSTRACT TRUNCATED AT 250 WORDS)

Endocrine responses and conception rates in fallow deer (Dama dama) following oestrous synchronization and cervical insemination with fresh or frozen-thawed spermatozoa

In Expt 1, 59 mature fallow deer does were allocated to six treatments (n = 9-10 per treatment). Does assigned to treatments 1, 2 and 3 each received an i.m. injection of 500 micrograms cloprostenol on day 13 of a luteal cycle. Does in treatments 2 and 3 received 50 or 100 iu pregnant mares' serum gonadotrophin (PMSG), respectively, at the time of prostaglandin administration. Does assigned to treatments 4, 5 and 6 each received single intravaginal controlled internal drug release (CIDR) devices for 14 days. Does in treatments 5 and 6 received 50 or 100 iu PMSG, respectively, at the time of CIDR device withdrawal. Incidence of oestrus was higher following treatment with CIDR devices than with prostaglandin (29 of 30 versus 12 of 29, P < 0.001). PMSG induced earlier onset of oestrus (34.6 +/- 0.9 h versus 44.7 +/- 2.4 h, P < 0.01) and reduced the range in the time to onset of oestrus (from 22 to 8 h for prostaglandin-treated does and from 36 to 14 h for progesterone-treated does). The number of LH surges was higher following treatment with CIDR devices than with prostaglandin (10 of 12 versus 3 of 12, P < 0.01). The overall mean peak LH concentration and time to LH peak were 30.2 +/- 3.4 ng ml-1 and 45.2 +/- 2.2 h after prostaglandin administration or CIDR device withdrawal. The overall median time of ovulation was 26 h after the onset of oestrus.(ABSTRACT TRUNCATED AT 250 WORDS)

Social support and HIV

This paper reviews research about the relationship between social support and health for people with HIV. Current studies linking social support and HIV are described and the major findings summarized in order to identify gaps in the literature. It is argued that, to date, research in this area has focused primarily upon gay white men in the USA at a symptomatic stage of the illness. There are few studies which have considered the impact of social position on the relationship between social support and health, and few which have included HIV-negative controls. Whilst there is evidence of a link between social support and the psychological well-being of people with HIV, research is still in its infancy. Much information is required about which particular aspects of social support and health are associated, how this association changes over time according to the stage of the disease, and with the socio-economic and cultural characteristics of those with HIV.

Auditory successive conditional discrimination and auditory stimulus equivalence classes

This paper describes an experimental demonstration of stimulus equivalence classes consisting entirely of auditory stimuli. Stimuli were digitized arbitrary syllables (e.g., "cug," "vek") presented via microcomputer. Training and testing were conducted with a two-choice auditory successive conditional discrimination procedure. On each trial, auditory samples and comparisons were presented successively. As each comparison was presented, a response location (a rectangle) appeared on the computer screen. After all stimuli for a trial were presented, subjects selected one of the response locations. Six subjects acquired the conditional discrimination baseline, 4 subjects demonstrated the formation of three-member auditory equivalence classes resulting from sample-S+ relations, and 1 subject demonstrated equivalence classes resulting from sample-S- relations. Four subjects received additional training and subsequently demonstrated expansion of the three-member classes to four members each.

Evidence for distinctive and intrinsic defects in insulin action in polycystic ovary syndrome

Women with PCO have a unique but poorly characterized disorder of insulin action. Obese (n = 16) and nonobese (n = 14) PCO women and age- and weight-matched normal, nondiabetic ovulatory women (obese, n = 15; nonobese, n = 17) had insulin action determined in vivo with sequential multiple insulin dose euglycemic clamps and in isolated abdominal adipocytes to clarify the mechanisms of insulin resistance. PCO resulted in significant increases in the ED50 insulin for glucose utilization in vivo (P less than 0.001) and in adipocytes (P less than 0.01), without significant changes in adipocyte insulin-binding sites. PCO also resulted in significant decreases in maximal insulin-stimulated rates of glucose utilization in vivo (P less than 0.01) and in adipocytes (P less than 0.01). Obesity resulted in smaller decreases in insulin sensitivity than PCO (ED50 insulin, P less than 0.001 in vivo and P less than 0.05 in adipocytes), but greater decreases in insulin responsiveness (Vmax, P less than 0.001 in vivo and in adipocytes). The ED50 insulin for suppression of HGP was increased only in obese PCO women (P less than 0.001), and the interactions between PCO and obesity on this parameter were statistically significant. No significant correlations between androgen or estrogen levels and adipocyte insulin binding or action were found. Because insulin binding was not changed, we conclude that the major lesion causing insulin resistance in PCO is a striking decrease in insulin sensitivity secondary to a defect in the insulin receptor and/or postreceptor signal transduction. PCO also is associated with modest but significant decreases in glucose transport. These defects in insulin action appear to represent intrinsic abnormalities that are independent of obesity, metabolic derangements, body fat topography, and sex hormone levels. Conversely, changes in hepatic insulin sensitivity appear to be acquired with obesity.

Evidence for distinctive and intrinsic defects in insulin action in polycystic ovary syndrome

Women with PCO have a unique but poorly characterized disorder of insulin action. Obese (n = 16) and nonobese (n = 14) PCO women and age- and weight-matched normal, nondiabetic ovulatory women (obese, n = 15; nonobese, n = 17) had insulin action determined in vivo with sequential multiple insulin dose euglycemic clamps and in isolated abdominal adipocytes to clarify the mechanisms of insulin resistance. PCO resulted in significant increases in the ED50 insulin for glucose utilization in vivo (P less than 0.001) and in adipocytes (P less than 0.01), without significant changes in adipocyte insulin-binding sites. PCO also resulted in significant decreases in maximal insulin-stimulated rates of glucose utilization in vivo (P less than 0.01) and in adipocytes (P less than 0.01). Obesity resulted in smaller decreases in insulin sensitivity than PCO (ED50 insulin, P less than 0.001 in vivo and P less than 0.05 in adipocytes), but greater decreases in insulin responsiveness (Vmax, P less than 0.001 in vivo and in adipocytes). The ED50 insulin for suppression of HGP was increased only in obese PCO women (P less than 0.001), and the interactions between PCO and obesity on this parameter were statistically significant. No significant correlations between androgen or estrogen levels and adipocyte insulin binding or action were found. Because insulin binding was not changed, we conclude that the major lesion causing insulin resistance in PCO is a striking decrease in insulin sensitivity secondary to a defect in the insulin receptor and/or postreceptor signal transduction. PCO also is associated with modest but significant decreases in glucose transport. These defects in insulin action appear to represent intrinsic abnormalities that are independent of obesity, metabolic derangements, body fat topography, and sex hormone levels. Conversely, changes in hepatic insulin sensitivity appear to be acquired with obesity.

Chronic high-dosage androgen administration to ovulatory women does not alter adrenocortical steroidogenesis

OBJECTIVE

To evaluate the role of chronic long-term exogenous androgen administration to normal ovulatory women on adrenal steroidogenesis.

DESIGN

Prospective study of four consecutive female-to-male transsexuals before and during chronic testosterone (T) therapy.

SETTING

Clinical Research Center of the Mount Sinai Medical Center.

PATIENTS

Four female-to-male transsexuals were studied before and during 6 to 12 months of chronic T enanthate therapy for desired virilization. All four subjects were ovulatory before treatment. Adrenocorticotropic hormone (ACTH) testing was performed before, and 6 and 12 months of androgen therapy and various adrenal androgens as well as precursor:product pairs were evaluated as an index of specific adrenocortical biosynthetic defects.

RESULTS

Baseline and 1 hour after 0.25 mg ACTH intravenously, adrenal androgen levels as well as adrenal precursor/product pairs demonstrated no difference before and during chronic T treatment. Studies included determinations of plasma 17-hydroxypregnenolone, 17-hydroxyprogesterone, dehydroepiandrosterone, androstenedione, 11-deoxycortisol, and cortisol.

CONCLUSION

It is concluded that chronic hypertestosteronemia does not alter adrenal steroidogenesis.

The nonequivalence of behavioral and mathematical equivalence

Sidman and his colleagues derived behavioral tests for stimulus equivalence from the axiom in logic and mathematics that defines a relation of equivalence. The analogy has generated abundant research in which match-to-sample methods have been used almost exclusively to study interesting and complex stimulus control phenomena. It has also stimulated considerable discussion regarding interpretation of the analogy and speculation as to its validity and generality. This article reexamines the Sidman stimulus equivalence analogy in the context of a broader consideration of the mathematical axiom than was included in the original presentation of the analogy and some of the data that have accumulated in the interim. We propose that (a) mathematical and behavioral examples of equivalence relations differ substantially, (b) terminology is being used in ways that can lead to erroneous conclusions about the nature of the stimulus control that develops in stimulus equivalence experiments, and (c) complete analyses of equivalence and other types of stimulus-stimulus relations require more than a simple invocation of the analogy. Implications of our analysis for resolving current issues and prompting new research are discussed.

Using stimulus equivalence procedures to teach name-face matching to adults with brain injuries

On pretests, 3 men with brain injuries matched dictated names of three therapists to written names, but did not match dictated or written names to photos, produce correct names in response to photos, locate offices given written names, or name therapists on sight. Match-to-sample training established conditional relations between dictated names and photos. Posttests showed the emergence of untrained conditional relations involving photos and written names, indicating development of three classes of equivalent stimuli (each containing a dictated name, photo, and written name). For 1 participant, conditional relations involving photos of office nameplates were also examined, but did not emerge pre- or posttraining. Two participants produced names orally when given photos and sorted written names and faces together after training; the 3rd participant was unavailable for these posttests. After training, 1 participant located and named all three therapists in their offices.

Acanthosis Nigricans, insulin action, and hyperandrogenism: clinical, histological, and biochemical findings

Acanthosis nigricans (AN) is a frequent clinical finding in hyperandrogenic women. Its presence has been used to subgroup such women. We performed this study in order to determine the actual histological prevalence of AN and its relationship to sex hormone levels and insulin action. Insulin-mediated glucose disposal was determined by the euglycemic clamp technique, and neck or axillary skin biopsies were graded blind for the presence and severity of AN in lean and obese women with the polycystic ovary syndrome (PCO) and in age- and weight-matched normal ovulatory controls. AN was present on clinical examination in 11 of 13 obese PCO, 3 of 6 lean PCO, 4 of 14 obese normal, and 0 of 4 lean normal women. AN was present on histological examination in 13 of 13 obese PCO, 5 of 6 lean PCO, 13 of 14 obese normal, and 1 of 4 lean normal women. The severity of histological AN was most highly correlated with insulin-mediated glucose disposal (r = -0.61; P less than 0.001) rather than fasting (r = 0.46; P less than 0.05) or glucose-stimulated insulin levels (r = 0.48; P less than 0.01). The only sex steroid correlated with histological AN was dehydroepiandrosterone sulfate (r = 0.46; P less than 0.01). We conclude that 1) clinical skin examination was very insensitive for detecting AN; 2) the best biochemical correlate of histological AN was decreased insulin action, rather than insulin or androgen levels per se; and 3) AN is a very common epiphenomenon of insulin resistance, and its clinical presence should not be used as a criterion for stratifying hyperandrogenic women.