229 NEW STROKE EARLY SUPPORTED DISCHARGE SERVICE PROVIDES ALTERNATIVE REHAB PATHWAY AND IMPROVES PATIENT AND ORGANISATIONAL OUTCOMES

Background

Early Supported Discharge (ESD) for stroke is an international model of best care for stroke patients. ESD improves patient outcomes while facilitating a faster hospital discharge through providing stroke specific rehabilitation at home. ESD can be expected to improve disability outcomes and quality of life and reduce length of hospital stay. A pilot ESD service was introduced to this model 3 hospital in 2021 which encompasses a large geographical rural area that historically had an absence of Stroke rehabilitation services.

Methods

A retrospective review of routine data extracted from 57 patients accepted to the ESD service in 2021 was completed. This initial examination explored the effectiveness of ESD with the population in this rural area. Service Objectives as follows: (1) Improve patient’s functioning as measured by Functional Independence Measure (FIM) and Functional Assessment Measures (FAM); (2) Demonstrate a reduction in disability outcomes as evidenced on the Modified Rankin Scale (MRS); (3) Increase number of early supported discharges directly home for patients; and (4) Reduce length of hospital stay for patients post-stroke.

Results

Implementation of an ESD service over a 12-month period achieved the following: (1) 8.1% improvement in total FIM/FAM scores indicating positive functional outcomes and enhanced independence when discharged home with ESD; (2) A decrease in the average MRS score indicating improved disability outcomes; (3) 25% of all stroke patients in 2021 were discharged with ESD rehabilitation; (4) An increase of 12% in total number of discharges home post stroke from 2020 to 2021; (5) 244 bed saving days.

Conclusion

The introduction of an ESD service resulted in patient and organisational benefits. Participation in ESD rehabilitation had a positive impact on reduction of disability scores captured using MRS and improvements in functional outcome measure scores captured using the FIM/FAM.

Epidemiological assessment of continuing transmission of lymphatic filariasis in Samoa

Ongoing transmission of lymphatic filariasis (LF) was assessed in five Samoan villages by measuring microfilaraemia (Mf), circulating filarial antigen (CFA) and antibody prevalence. Compared to the other villages, Fasitoo-Tai had a significantly higher Mf prevalence (3·2%), CFA prevalence (14·6%) and antibody prevalence in children (62·0%) (P<0·05). Puapua had a significantly lower CFA prevalence (2·5%), no detectable Mf-positive individuals and significantly low antibody prevalence in children (7·9%) (P<0·05). Siufaga, previously believed to be LF-free, recorded >1% CFA prevalence and a high antibody prevalence in children (46·6%). Overall, antibody prevalence in children appeared to reflect the transmission dynamics in the villages and, in Siufaga, identified an area of ongoing transmission. The Filariasis Cellabs Enzyme-Linked Immunosorbent Assay (CELISA), based on recombinant antigen Bm14, to detect antibodies, could potentially be a promising diagnostic tool for inclusion in future surveillance in the South Pacific.

An optimized method for extraction and detection of Coconut cadang-cadang viroid(CCCVd) from oil palm

Coconut cadong-cadong viroid (CCCVd) causes the Lethal cadang-cadang disease of coconut palms in the Philippines and it is recently reported to be associated with the orange spotting disease on oil palm in Malaysia. The low concentration of the viroid RNA in oil palm as well as the high content of polyphenols and polysaccharides in this plant which interfere with the purification steps makes it difficult to extract and detect this viroid from oil palm. A previously described method was modified and optimized for extraction and detection of CCCVd from infected oil palms. Briefly, 7 g of leaf material was homogenized in a mortar or a blender using liquid nitrogen. 10 ml of extraction buffer (100 mM Tris-HCl pH 7.5, 100 mM NaCl, 10 mM EDTA) along with 100 mM 2-mercaptoethanol and 10 ml water saturated phenol was added to the frozen powder. After centrifuging at 4 degrees C, 4000 g for 30 min, the aqueous phase was extracted once more with phenol then once with chloroform-isoamyl alcohol (24:1). After adding sodium acetate, pH 5.6 to 200 mM, the mixture was precipitated with 2.5 vol ethanol overnight in -20 freezer and then the pellet was washed with 70% ethanol and air-dried. One milliliter of 8 M LiCl was added to the dried pellet and after shaking overnight at 4 degrees C and another centrifugation step the supernatant was collected and precipitated again with ethanol and then the resulting pellet was washed and air-dried. To carry out northern blotting, samples equivalent to 40 g of plant tissue were mixed with formamide buffer and loaded onto a 12% polyacrylamide gel containing 7 M urea and after separation by electrophoresis, were electroblotted onto membrane and fixed by UV cross-linking. Pre-hybridization and hybridization using hybridization buffer (50% formamide, 25%SSPE, 0.1% Ficol and PVP, 0.1 % SDS, 0.02 % DNA (5mg/ml)) was carried out at 45 degrees C for 90 min and 16 h, respectively followed by two low stringency washes (0.5 X SSC, 0.1% SDS, at room temperature for 5 min) and one high stringency wash (0.1X SSC, 0.1% SDS at 60 degrees C for 1 hour). In vitro synthesized DIG-labeled full-length CCCVd(-) RNA probe was used in hybridization step. DIG Nucleic Acid Detection Kit (Roche) instructions were followed for detection procedure and as a result the blue bands corresponding to the position of the viroid were appeared on the membrane. The result of this study showed the ability of DIG labeled probe in detection of the viroid and also provided a suitable extraction and hybridization method for the detection of CCCVd from oil palm.

Time to treat: A system redesign focusing on decreasing the time from suspicion of lung cancer to diagnosis in a community hospital

17005

Background: Multiple physician visits, numerous investigations, and serial wait times often result in a lengthy process from the onset of lung cancer-related symptoms until diagnosis. An unpublished retrospective chart review from a Toronto community hospital indicated suboptimal delays for patients from onset of symptoms until the diagnosis of lung cancer. Methods: The Time to Treat Program (TTT), consisting of a streamlined referral system and a clerical facilitator to fast-track patients through a diagnostic pathway algorithm, was designed for patients with clinical or radiological suspicion of lung cancer. Data on patient visits and investigations were collected. Pre- and post-implementation data on median wait times were compared. Results: From April 2005 to December 2006 over 120 physicians referred 188 females and 226 males. For the majority of patients (95.2%), the reason for referral was chest x-ray findings suspicious for lung cancer. After TTT implementation, the median time from suspicion of lung cancer to referral for specialist consultation decreased from 19.9 days to 10 days, and the median time from such referral to the actual consultation date decreased from 16.8 days to 5.3 days. The median time from specialist consultation to CT scan decreased from 52.1 days to 4 days and the median time from CT to diagnosis decreased from 39 days to 12.4 days. Overall, the median time from suspicion of lung cancer to diagnosis decreased from 127.8 days to 30 days. For 25% of the patients in the TTT it took 13 or fewer days from suspicion of lung cancer to diagnosis, while for 5% of the patients it took 90 days or more. Half of the patients in the TTT had a diagnosis by 24 days from the time of suspicion. Of all patients in the TTT, 33% were eventually diagnosed with lung cancer. The time from suspicion to diagnosis took longer for patients who eventually had confirmed lung cancer than those who did not: 36.5 days vs. 28.7 days. Conclusions: By addressing process issues in the work-up of lung cancer, the TTT was effective in shortening the time from suspicion of lung cancer to diagnosis and reduced time intervals at each step in the process. Earlier diagnosis of lung cancer may allow increased treatment options for patients.

No significant financial relationships to disclose.

Plasma erythropoietin levels in the oldest old

Erythropoietin (EPO) regulates erythrocytes production and is synthesized mainly by the kidney. Its production is reduced during chronic renal failure but is not altered by the senescence process in spite of the morphological changes that occur in the kidney. However, there is no information regarding what happens to erythropoietin synthesis during advanced ageing. Thus, we carried out an investigation to determine whether there was any significant difference in plasma erythropoietin between adults, old and very old people.

MATERIAL AND METHODS

We studied 74 healthy volunteers: 22 adults, 30 old, and 22 very old. None of them were smokers or were suffering from any disease that may intefere with hemoglobin (Hb) levels or with EPO production. Hematocrit, Hb, plasma creatinine and plasma erythropoietin were measured, and creatinine clearance was calculated from serum creatinine using two different formulae. Statistical analysis was performed using ANOVA and Bonferroni tests.

RESULTS AND CONCLUSION

Among the three groups we found a significant difference in creatinine clearance (p < 0.001), but not in plasma erythropoietin levels; we conclude that normal senescence does not alter plasma erythropoietin levels, even during advanced ageing.

Hepatitis C and substance use in a sample of homeless people in New York City

This study examined the prevalence of hepatitis C virus (HCV) antibodies and its association with substance use and sexual behavior among a sample of 139 persons visiting a mobile medical clinic in Manhattan. Ninety percent were unstably housed or were living on the street. The prevalence of HCV antibodies was 32%. Prevalence was also high for hepatitis B core antibodies (47%), HIV antibodies (15%), and syphilis exposure (14%); 76% tested positive for cocaine. Among subjects who reported ever injecting (20%), 86% were HCV positive; 19% of non-injectors were HCV positive. In separate multivariate logistic regression models (with injection controlled), HCV was predicted by quantitative hair assays for cocaine and self-reported duration of crack-cocaine use. Alcohol dependence and sexual behavior did not predict HCV. Hepatitis C is a significant public health problem among the urban homeless population, with injection drug use and, to a lesser extent, cocaine use implicated as risk factors.

Integrating the methadone patient in the traditional addiction inpatient rehabilitation program--problems and solutions

Physicians have reported alcoholism and opioid addiction as co-morbid conditions since the 19th century. From the inception of methadone maintenance treatment, heroin addicts with serious alcohol conditions have enrolled in methadone maintenance programs. Programs that treat alcoholism, including the traditional addiction inpatient rehabilitation programs of the Addiction Treatment Centers (ATCs) operated by New York State, have based their treatment regimen on 12-step abstinence models. Methadone maintenance was considered antithetical to this philosophy. It was regarded as simply substituting one drug for another and not a legitimate treatment for opiate dependence. Therefore, methadone patients were often not accepted into alcohol treatment programs, since they were perceived as active addicts taking a mood-altering drug. Alcohol-related conditions among methadone patients are major causes of liver disease and death, and behavior problems associated with excessive drinking are major reasons for discharging patients. To address these issues and the lack of treatment facilities, the administration of the New York State Office of Alcoholism and Substance Abuse Services (OASAS), which licenses both methadone programs and the ATCs in New York State, realized that many of the methadone patients with alcohol problems are in need of the services provided at the ATCs. They instituted, therefore, a rigorous educational effort for the medical and counseling staffs of the ATCs, designed to integrate methadone treatment into the ATC treatment framework. Eighty percent of the 220 methadone patients who entered the ATCs in a demonstration project during the 1997/1998 state fiscal year have been compliant with the treatment regimen. These results have led to acceptance of methadone patients into the ATCs.

[Effect of rheumatoid arthritis associated HLA-DRbeta1 subtypes on protein kinase A signaling]

OBJECTIVE

To investigate the impact of rheumatoid arthritis (RA)-associated HLA-DRbeta(1) (*)0401, (*)0402, (*)0403 and (*)0404 subtypes on protein kinase A (PKA) signaling.

METHODS

To detect the activities of adenylate cyclase (AC), cAMP and PKA in transfectants expressing rheumatoid arthritis-associated HLA-DRbeta(1) subtypes and their mutants.

RESULTS

The levels of AC, cAMP and PKA of HLA-DRbeta(1) (*)0401 and (*)0404 transfectants were significant lower than that of HLA-DRbeta(1) (*)0402 and (*)0403 transfectants (P < 0.01). The mutant HLA-DRbeta(1) (*)0403 transfectants expressing DRRAE or QRRAA secreted lower levels of PKA, cAMP and AC (P < 0.01).

CONCLUSION

RA-associated HLA-DRbeta(1) (*)0401 and (*)0404 expression suppressed intracellular PKA signaling pathway, and may mediate abnormal intracellular signaling in rheumatoid arthritis.

Selected in-treatment outcomes of long-term methadone maintenance treatment patients in New York State

The New York State Office of Alcoholism and Substance Abuse Services (OASAS) licenses the largest system of methadone maintenance clinics nationwide. In 1996, a survey was undertaken to evaluate the functioning of patients continuously active in treatment for ten or more years. Information was obtained on a 10% random sample from the OASAS client data system and the records of the clinics. Data were collected concerning methadone dose, illicit drug and problematic alcohol use, employment, criminal activity, health, living situations, and the primary type of payment for treatment. A contrast group was constructed of discharged patients who had no more than 5 years of continuous treatment. The long-term active patients in the study sample showed superior outcomes on all variables, although some of the differences were small. However, the arrest rate for the discharged contrast group was 20 times as large as the arrest rate for the active study sample. These results are consistent with nationwide evaluations of methadone maintenance treatment. Factors that negatively impacted on the adjustments of the active patients were heavy use of crack/cocaine and disabilities. The long-term active patients in this sample belong to distinct subgroups with different levels of functioning, achievement, and ongoing health and social needs that must be investigated and addressed.

Reduced antibody response to revaccination with meningococcal serogroup A polysaccharide vaccine in adults

Widespread use of meningococcal A and C polysaccharide (MACP) vaccines has raised concerns about induction of hyporesponsiveness to these polysaccharides. Immunological hyporesponsiveness to C polysaccharide has been clearly documented in infants, children and adults but only limited data from Gambian children are available for A polysaccharide. We investigated whether a second dose of MACP, given 6 months after an initial dose affected the immunological response as measured by the serum bactericidal assay (SBA) and enzyme-linked immunosorbent assay (ELISA), to serogroup A meningococci in young adults (university students, n=36). Serogroup A SBA responses 1 month following the second dose of MACP (geometric mean titre (GMT) 103.6, 95% CI 45.6-235.1) were approximately one third of the levels observed 1 month post first dose (GMT 281.9, 95% CI 134.9-581.4). The serogroup A-specific IgG levels post second dose (GMC 21.2, 95% CI 15.3-29.4) were also significantly lower at an average of three-quarters the level post first dose (GMC 28.7, 95% CI 20.8-39.7). This confirms that revaccination with MACP vaccine, 6 months following the initial dose, results in a reduced immunological response to A polysaccharide in adults. Repeated vaccination with MACP vaccine may be ineffective and development and use of meningococcal serogroup A conjugate vaccines should be encouraged.

Methadone maintenance treatment (MMT): a review of historical and clinical issues

Methadone maintenance has been evaluated since its development in 1964 as a medical response to the post-World War II heroin epidemic in New York City. The findings of major early studies have been consistent. Methadone maintenance reduces and/or eliminates the use of heroin, reduces the death rates and criminality associated with heroin use, and allows patients to improve their health and social productivity. In addition, enrollment in methadone maintenance has the potential toreduce the transmission of infectious diseases associated with heroin injection, such as hepatitis and HIV. The principal effects of methadone maintenance are to relieve narcotic craving, suppress the abstinence syndrome, and block the euphoric effects associated with heroin. A majority of patients require 80-120 mg/d of methadone, or more, to achieve these effects and require treatment for an indefinite period of time, since methadone maintenance is a corrective but not a curative treatment for heroin addiction. Lower doses may not be as effective or provide the blockade effect. Methadone maintenance has been found to be medically safe and nonsedating. It is also indicated for pregnant women addicted to heroin. Reviews issued by the Institute of Medicine and the National Institutes of Health have defined narcotic addiction as a chronic medical disorder and have claimed that methadone maintenance coupled with social services is the most effective treatment for this condition. These agencies recommend reducing governmental regulation to facilitate patients access to treatment. In addition, they recommend that the number of programs be expanded, and that new models of treatment be implemented,if the nationwide problem of addiction is to be brought under control. The National Institutes of Health also recommend that methadone maintenance be available to persons under legal supervision, such as probationers, parolees and the incarcerated. However, stigma and bias directed at the programs and the patients have hindered expansion and the effective delivery of services. Professional community leadership is necessary to educate the general public if these impediments are to be overcome.

Causes and rates of death among methadone maintenance patients before and after the onset of the HIV/AIDS epidemic

Causes of death and the mortality rates of active methadone patients and those who had left treatment were compared. Prior to the HIV epidemic, death rates among discharged methadone patients were more than twice that of patients who continued with their methadone treatment. However, the death rate from heroin-related causes in the post-treatment period was 51 times the rate among active patients. Alcohol-related conditions were the leading causes of death in patients more than 30 years old on methadone. During the post-treatment period, alcohol-related deaths were second to those of heroin-related causes. Alcohol-related deaths were particularly pronounced among black patients. Death rates among active male and female patients were identical, but the death rate for discharged female patients was greater than for discharged males. With the onset of the HIV epidemic in the 1980s, AIDS-related causes became the major cause of death in treatment. However, other causes of death, such as alcohol and other medical conditions, identified prior to the AIDS epidemic, persisted. AIDS-related deaths peaked in the mid-1990s and have recently subsided. However, within the past two years, deaths related to HCV have increased to 9% of all patient deaths in a major methadone program. With the emergence of HCV, deaths from this cause are expected to eclipse AIDS-related deaths within the next decade.

Methadone medical maintenance (MMM): treating chronic opioid dependence in private medical practice--a summary report (1983-1998)

BACKGROUND

Methadone Medical Maintenance (MMM) was implemented in 1983 to enable socially rehabilitated methadone patients to be treated in the offices of private physicians rather than in the traditional clinic system. Over a period of 15 years, 158 methadone patients who fulfilled specific criteria within the clinic system entered this program in New York City. Participating patients reported to their physician once a month and received a one-month supply of methadone tablets rather than a one-day liquid dose in a bottle.

METHOD

Of the 158 patients who entered this program, 132 (83.5%) were compliant with the regulations and proved to be treatable within the hospital-based private practices of internists participating in the program. Compliant MMM patients found it easier to improve their employment status and business situations, finish their educations, and normalize their lives in MMM as opposed to the traditional clinic system because they had simplified reporting schedules and fewer clinical restrictions. Twelve (8%) compliant patients were able to successfully withdraw from methadone after an average of 17.7 years of treatment in both the traditional clinics and MMM. Twenty compliant patients (13%) died from a variety of causes, 40% of which were related to cigarette smoking. None of the deaths were attributable to long-term methadone treatment. Other causes of death included hepatitis C, AIDS, cancer, homicide, complications of morbid obesity and meningitis.

RESULTS

The 26 noncompliant patients (16.5%) were referred back to their clinics for continued treatment or were discharged for failure to report as directed. A major cause of failure in MMM was abuse of crack/cocaine.

CONCLUSIONS

Stigma concerning enrollment in methadone treatment was a major social issue that patients faced. Many refused to inform employers, members of their families, friends, and other physicians who treated them for a various of conditions that they were methadone patients. The methadone medical maintenance physician, therefore, functions as a medical ombudsman for the patient, educating other physicians who treat the patient about methadone maintenance and its applicability to the patient. Our results can serve as a model for the expansion of office-based MMM treatment.

The association between cocaine use and HIV/STDs among soup kitchen attendees in New York City

We examined the associations of cocaine use with HIV/sexually transmitted diseases (STDs) in a sample of 184 soup kitchen attendees using a mobile medical van in Manhattan (male = 66%; black or Hispanic = 81%; cocaine use, primarily crack = 75%; ever injected drugs = 22%). In addition to confirming the association between years of cocaine use and HIV antibodies in this sample (odds ratio [OR] = 2.11; p <.05) we examined the pattern of associations of cocaine use and non-HIV STDs under the hypothesis that the strength of an association depends on the efficiency of sexually transmitting a particular STD (high, moderate, and low for syphilis, hepatitis B and hepatitis C, respectively). As predicted, years of cocaine use was strongly associated with syphilis (OR = 2.07; p <.05), moderately associated with hepatitis B core antibodies (OR = 1.50; p <.05), and not significantly associated with hepatitis C antibodies (OR = 1.48; p >.05). A reverse pattern of associations between opiate use (injection drug use) and the three STDs points to the singular significance of cocaine use in the sexual transmission of STDs, and by inference, HIV. This conclusion is further bolstered by correlations of biologic (hair assays) and self-reported measurements of cocaine use (but not opiates) with self-reports of high risk sexual behavior among the women (number of partners and selling sex) and men (number of partners and buying sex). These data underscore the need for effective cocaine treatment and HIV interventions tailored to the large numbers of cocaine users in inner cities.

Substance misuse and related infectious diseases in a soup kitchen population

Representative samples of female (N = 119) and male (N = 100) guests were selected at two inner city soup kitchens. In the preceding month, 75% used cocaine/crack and 25% used heroin/opiates as determined by hair analysis. Relatively few guests (25%) were in substance dependency treatment. Infectious disease rates were: HIV (16%), hepatitis B exposure (21%), hepatitis B carrier (6%), syphilis exposure (15%). Years of injecting drug use and homelessness/marginal housing were associated with HIV infection and hepatitis B exposure. Soup kitchens should be prime locations for outreach to cocaine/crack and heroin users in need of treatment, medical care, and interventions to prevent infectious disease transmission.

Reactivation of latent tuberculosis: variations on the Cornell murine model

Mycobacterium tuberculosis causes active tuberculosis in only a small percentage of infected persons. In most cases, the infection is clinically latent, although immunosuppression can cause reactivation of a latent M. tuberculosis infection. Surprisingly little is known about the biology of the bacterium or the host during latency, and experimental studies on latent tuberculosis suffer from a lack of appropriate animal models. The Cornell model is a historical murine model of latent tuberculosis, in which mice infected with M. tuberculosis are treated with antibiotics (isoniazid and pyrazinamide), resulting in no detectable bacilli by organ culture. Reactivation of infection during this culture-negative state occurred spontaneously and following immunosuppression. In the present study, three variants of the Cornell model were evaluated for their utility in studies of latent and reactivated tuberculosis. The antibiotic regimen, inoculating dose, and antibiotic-free rest period prior to immunosuppression were varied. A variety of immunosuppressive agents, based on immunologic factors known to be important to control of acute infection, were used in attempts to reactivate the infection. Although reactivation of latent infection was observed in all three variants, these models were associated with characteristics that limit their experimental utility, including spontaneous reactivation, difficulties in inducing reactivation, and the generation of altered bacilli. The results from these studies demonstrate that the outcome of Cornell model-based studies depends critically upon the parameters used to establish the model.

Overexpression of a kinase-deficient transforming growth factor-beta type II receptor in mouse mammary stroma results in increased epithelial branching

Members of the transforming growth factor-beta (TGF-beta) superfamily signal through heteromeric type I and type II serine/threonine kinase receptors. Transgenic mice that overexpress a dominant-negative mutation of the TGF-beta type II receptor (DNIIR) under the control of a metallothionein-derived promoter (MT-DNIIR) were used to determine the role of endogenous TGF-betas in the developing mammary gland. The expression of the dominant-negative receptor was induced with zinc and was primarily localized to the stroma underlying the ductal epithelium in the mammary glands of virgin transgenic mice from two separate mouse lines. In MT-DNIIR virgin females treated with zinc, there was an increase in lateral branching of the ductal epithelium. We tested the hypothesis that expression of the dominant-negative receptor may alter expression of genes that are expressed in the stroma and regulated by TGF-betas, potentially resulting in the increased lateral branching seen in the MT-DNIIR mammary glands. The expression of hepatocyte growth factor mRNA was increased in mammary glands from transgenic animals relative to the wild-type controls, suggesting that this factor may play a role in TGF-beta-mediated regulation of lateral branching. Loss of responsiveness to TGF-betas in the mammary stroma resulted in increased branching in mammary epithelium, suggesting that TGF-betas play an important role in the stromal-epithelial interactions required for branching morphogenesis.

Treatment with farnesyl-protein transferase inhibitor induces regression of mammary tumors in transforming growth factor (TGF) alpha and TGF alpha/neu transgenic mice by inhibition of mitogenic activity and induction of apoptosis

Mouse mammary tumor virus-transforming growth factor alpha (MMTV-TGF alpha) and MMTV-TGF alpha/neu transgenic mice develop mammary tumors after a long latency and therefore provide useful model systems for breast cancer with its recognized activation of receptor tyrosine kinase signaling. We used these mice to study the antitumor effect of L-744,832 (FTI), a potent and selective inhibitor of farnesyl-protein transferase, and hence of Ras function. A total of 55 mice were assigned randomly to treatment with FTI or vehicle, and one-half of the mice were crossed over after initial treatment to the opposite group. L-744,832 induced reversible regression of mammary tumors that was paralleled by a decrease in serum levels of TGF alpha secreted by the tumor cells. There was no difference in response to treatment with FTI between MMTV-TGF alpha mice, in which tumorigenesis was accelerated by multiparity or the chemical carcinogen 7,12-dimethylbenzanthracene, and MMTV-TGF alpha/neu mice. The tumor histological type had no impact on FTI sensitivity. For mechanistic analyses, tumor excision biopsies were obtained from 12 mice before and after treatment with L-744,832. In these samples, tumor regression was paralleled biochemically by inhibition of mitogen-activated protein kinase activity and biologically by an increase in G1-phase and decrease in S-phase fractions, as well as induction of apoptosis. These results suggest that the potential clinical use of FTI could be expanded to include cancers harboring activated receptor tyrosine kinases as well as those containing activated Ras.

Dominant-negative interference of the transforming growth factor beta type II receptor in mammary gland epithelium results in alveolar hyperplasia and differentiation in virgin mice

Transforming growth factor (TGF)-beta1 and TGF-beta3 are normally expressed at high levels in the mammary gland during quiescence and at all stages of development, except lactation. Exogenously added TGF-beta1, -beta2, and -beta3 have been shown to regulate growth and differentiation of mammary epithelial cells in vitro and in vivo. TGF-betas signal through a heteromeric complex of type I and type II serine/threonine kinases. The type II receptor is necessary for ligand binding and growth suppression by TGF-betas. Deletions of the cytoplasmic domains of several kinase receptors known to function in multimeric complexes have been shown to act as dominant-negative mutations. To evaluate the role of endogenous TGF-betas in the growth and differentiation of the mammary gland in vivo, we have targeted expression of a truncated, kinase-defective TGF-beta type II receptor to mammary epithelial cells in transgenic mice using the mouse mammary tumor virus promoter/enhancer. Transgene expression was localized to the epithelial cells of terminal ducts and alveolar buds. At approximately 20 weeks of age, virgin female transgenic mice demonstrated varying degrees of mammary epithelial hyperplasia. Mammary glands from transgenic, virgin animals exhibited alveolar development and expression of the milk protein, beta-casein. The data suggest that impaired responsiveness in the epithelium to endogenous TGF-betas results in inappropriate alveolar development and differentiation in the mammary gland. We conclude that endogenous TGF-betas signal to the epithelium to maintain quiescence in the mammary glands of virgin animals.

Expression of heat shock genes in Clostridium acetobutylicum

Characterization of the heat shock response in Clostridium acetobutylicum has indicated that at least 15 proteins are induced by a temperature upshift from 30 to 42 degrees C. These so-called heat shock proteins include DnaK and GroEL, two highly conserved molecular chaperones. Several genes encoding heat shock proteins of C. acetobutylicum have been cloned and analysed. The dnaK operon includes the genes orfA (a heat shock gene with an unknown function), grpE, dnaK, and dnaJ; and the groE operon the genes groES and groEL. The hsp18 gene coding for a member of the small heat shock protein family constitutes a monocistronic operon. Interestingly, the heat shock response in this bacterium is regulated by a mechanism, which is obviously different from that found in Escherichia coli. So far, no evidence for a heat shock-specific sigma factor of the RNA polymerase in C. acetobutylicum has been found. In this bacterium, like in many Gram-positive and several Gram-negative bacteria, a conserved inverted repeat is located upstream of chaperone/chaperonin-encoding stress genes such as dnaK and groEL and may be implicated as a cis-acting regulatory site. The inverted repeat is not present in the promoter region of hsp18. Therefore, in C. acetobutylicum there are at least two classes of heat shock genes with respect to the type of regulation. Evidence has been found that a repressor is involved in the regulation of the heat shock response in C. acetobutylicum. However, this regulation seems to be independent of the inverted repeat motif, and the mechanism by which the inverted repeat motif mediates regulation remains to be elucidated.(ABSTRACT TRUNCATED AT 250 WORDS)

A study of the use of clonidine and naltrexone in the treatment of opioid addiction in the former USSR

Sixty-eight opioid addicts in Moscow voluntarily entered a two phase study that employed the medications clonidine and naltrexone to withdraw addicts from narcotics and naltrexone for maintenance therapy. Of the 44 subjects entering the withdrawal phase, only 3 completed the procedure and entered naltrexone maintenance. All 27 subjects entering naltrexone maintenance left within 50 days against medical advice. Follow-up on about 75% of the subjects in both phases of the study showed they relapsed to opioid use after leaving treatment.

Outcomes of treatment of socially rehabilitated methadone maintenance patients in physicians' offices (medical maintenance): follow-up at three and a half to nine and a fourth years

OBJECTIVE

To determine whether selected socially rehabilitated former heroin addicts maintained on methadone can continue successful rehabilitation while maintained on methadone by primary care physicians rather than licensed clinics. This procedure has been termed "medical maintenance."

DESIGN

Cohort study with 42-111 months of follow-up.

SETTING

Offices of hospital staff physicians (internists or family practitioners).

PATIENTS

The 100 patients met extensive entry criteria, including five or more years in conventional methadone maintenance treatment; stable employment or other productive activity; verifiable financial support; and no criminal involvement, use of illegal drugs, or excessive alcohol use within three or more years.

MEASUREMENTS AND MAIN RESULTS

Outcome measures used were retention in treatment, discharge for one of several reasons, lost medication incidents, and substance abuse. At one, two, and three years of treatment, 98, 95, and 85 patients, respectively, remained in medical maintenance. Cumulative proportional survival in treatment was 0.735 +/- 0.048 at five years and 0.562 +/- 0.084 at nine years. After 42-111 months, 72 patients remained in good standing; 15 patients had unfavorable discharges (11 for cocaine use, three for misuse of medication, and one for administrative violations); seven voluntarily withdrew from methadone in good standing (after receiving it for 9.1-24.4 years); four died; one transferred to a chronic care facility; and one voluntarily left the program.

CONCLUSIONS

Carefully selected methadone maintenance patients in medical maintenance have a high retention rate and a low incidence of substance abuse and lost medication. Voluntary withdrawal from methadone maintenance after one or two decades is possible. The authors believe that medical maintenance should be made available to appropriate patients in other localities.

Medical maintenance: the treatment of chronic opiate dependence in general medical practice

Medical maintenance was created to treat rehabilitated methadone maintenance patients within the context of general medical practice. One hundred methadone patients who met screening criteria were transferred for continuing care from traditional methadone clinics either to the practices of hospital-based physicians or to a health maintenance organization. Patients see their physicians about once per month, submit urine samples at the time of the office visits, drink a dose of methadone in the presence of their doctor or nurse, and receive a 28-day supply of methadone in pill or tablet form. The methadone prescriptions are filled by the hospital pharmacies. Physicians are responsible for the patients' annual physicals and can treat patients for other conditions. In our initial analysis of medical maintenance, 82.5% of the patients remained in good standing and 5% left the program voluntarily in good standing; the remaining 12.5% who were unable to respond favorably were returned to clinic programs. For rehabilitated patients requiring long-term or life-long care, medical maintenance is a viable alternative to traditional clinic programs. With proper policies and procedures, medical maintenance can be implemented in many hospitals.

Ambivalence toward methadone treatment among intravenous drug users

Interviews were conducted with a sample of jailed intravenous opioid users who were not in treatment at the time of their arrest and who were admitted to an in-jail methadone maintenance program. At release, subjects were to be referred to dedicated slots in participating community methadone programs. Virtually all subjects were daily injectors of heroin and cocaine. Although the majority of subjects had previous episodes of methadone maintenance, most reported anxieties about methadone, such as bone decalcification and possible overdosing. Women and subjects who shared needles were more likely to report fears about methadone. Only 52% of the subjects stated that they intended to report to a methadone program after their release and 45% did not expect to remain in treatment for more than one year. Subjects who stated that they were not afraid of methadone, frequently injected drugs, and rarely used crack were more likely to express intentions to enroll and remain in community methadone treatment. Ambivalence toward methadone treatment may be a result of unrealistic concerns about the side effects of methadone and personal heuristics regarding the nature of addiction and the efficacy of treatment.

Absence of antibody to human immunodeficiency virus in long-term, socially rehabilitated methadone maintenance patients

Human immunodeficiency virus (HIV) infection has become widespread among parenteral drug abusers. We measured antibody to HIV and hepatitis B virus markers in 58 long-term, socially rehabilitated methadone-maintained former heroin addicts. None of the 58 had antibody to HIV, but one or more markers of hepatitis B virus infection were seen in 53 (91%). The duration of methadone maintenance was 16.9 +/- 0.5 years, and the median dose of methadone was 60 mg (range, 5 to 100 mg). Before methadone treatment, the patients had abused heroin parenterally for 10.3 +/- 1.7 years, and they had engaged in additional high-risk practices for HIV infection. We conclude that successful outcomes during methadone maintenance treatment are associated with sparing of parenteral drug abusers from HIV infection.

[Studies on the biological function of the nucleotide base of vitamin B12]

Studies on the coenzyme activity of some nucleotide base analogues of adenosylcobalamine in the dioldehydratase and methyl-malonyl-CoA mutase systems resulted in fundamental differences: Contrary to dioldehydratase the coenzyme activity remains in the methyl-malonyl-CoA mutase system when adenosyl-cobamides with a strongly modified nucleotide base are studied. The analogues give a good growth response with Escherichia coli. In the growth test with Lactobacillus leichmanii only the cobamides that do not have substituted nucleotide bases in the positions 2 or 3 of their imidazole ring are active.

Methadone maintenance patients in general medical practice. A preliminary report

Medical maintenance is the treatment by primary care physicians of rehabilitated methadone maintenance patients who are stable, employed, not abusing drugs, and not in need of supportive services. In this research project, physicians with experience in drug abuse treatment provided both the pharmacologic treatment of addiction as well as therapy for other medical problems, as needed. Decisions regarding treatment were based on the individual needs of the patient and on currently accepted medical practice rather than on explicit regulations. We studied the first 40 former heroin addicts who were transferred to this program from more conventional methadone clinics. At a follow-up visit at 12 to 55 months, 33 (82.5%) of 40 patients had remained in treatment; five (12.5%) had been discharged because of cocaine abuse and two (5%) had been voluntarily discharged. Personal benefits of medical maintenance include the dignity of a standard professional atmosphere and a more flexible reporting schedule. This program has the potential for improving treatment of selected methadone maintenance patients.

Cost effectiveness. How should it be determined?

The purpose of this article is to compare three commonly used indices of cost-effectiveness: the cost-effectiveness ratio, the cost-benefit ratio, and net benefit. We show that these indices can be interpreted to be consistent with one another and consistent with the traditional economic definition of cost-effectiveness. Further, we show that the relative cost-effectiveness of competing strategies cannot be determined by simply comparing their respective cost-benefit or cost-effectiveness ratios, but can be determined by comparing their respective net benefits. Finally, we show that cost-effectiveness ratios cannot be properly interpreted without consideration of the dollar value of health benefits.

Alcoholism and methadone treatment: consequences for the patient and program

The data on alcoholism presented in this paper were extracted from a major follow-up study of active and discharged methadone patients conducted from 1974 through 1977 in New York City. Alcoholism is a factor in 26% of the terminations from methadone treatment. It is also the leading cause of death in treatment and the second leading cause of death, following complications with opiates, in the post-treatment Also, patients with episodes of excessive drinking have markedly lower survival rates over a 10-year period when compared to patients who are social or moderate drinkers.

Degradation of 1,1-diphenylethylene by mixed cultures

A nonaxenic sewage culture metabolized 1,1-diphenylethylene by two different pathways involving hydration to form 2,2-diphenylethanol and oxidation and fission of one of the benzene rings to form atropic acid. Five different bacterial strains which grew on 1,1-diphenylethylene were isolated; all were gram-negative rods comprising the genera Pseudomonas, Acetomonas, and Acinetobacter. A fungal isolate, Cladosporium, which used diphenylethylene as a sole carbon source, was also obtained from the same enrichment procedure.

Isoprene and Rubber. Part 22. Isorubber Nitrone

Rubber Micelles or Macromolecules The idea of Pummerer that the parent molecule of rubber is [C5C8]8 is based upon molecular weight determinations carried out by him and his colleagues upon rubber in menthol and above all upon isorubber nitrone. This latter product, which has been prepared by Alessandri and again by Bruni and Geiger by the action of nitrosobenzene on rubber has, according to Pummerer and Gündel, the constitution [C5H6,C6H5NO]8. On this subject the authors say that: We made cryoscopic molecular weight determinations of isorubber nitrone iii benzene and nitrobenzene. Even in these generally used solvents the nitrone gives depressions which indicate a molecular weight lying between 1200 and 1400. For a parent rubber molecule of 8 isoprenes which reacts with 8 molecules of nitrosobenzene with a splitting off of 16 atoms of water, a weight of 1384 is calculated, agreeing very well with the above. As is the case with determinations of rubber in menthol, here the final measurements can be undertaken only when the constant is obtained (in this case after 1-2 hours) and not immediately after the solid substance disappears, for otherwise the value will be about 1000 or 2000 higher, which probably results from a still incomplete solution of the micelles. The study of isorubber nitrone, therefore, supports our opinion on the size of the parent rubber molecule which was expressed earlier. These opinions apparently do not conform to the view expressed by one of us some time ago, according to which rubber has a very high molecular weight, and the primary colloid particles, therefore, the particles in dilute solution, form macromolecules. These have a molecular weight of about 68,000, so that approximately 1000 isoprene residues are united in a chain . This concept was based on a study of models, especially on experiments on polysterol and further by conversion of rubber into colloid-soluble rubber-phosphonium salts, by the preparation of homologous polymeric series of polyprenes, by the decomposition of rubber, and finally by relations between viscosity and molecular weight in this series.