Effects of fentanyl and the adulterant levamisole on the rewarding and locomotor effects of methamphetamine in rats

BACKGROUND

People who use psychostimulant substances can be exposed to unknown adulterants, such as the synthetic opioid fentanyl (FEN) and the anthelmintic cholinergic agent levamisole (LEV). This work explores the rewarding and locomotor effects of methamphetamine (METH) in combination with FEN or LEV.

METHODS

We used adult male Wistar rats in the conditioned-place preference (CPP) paradigm (conditioning, extinction, and reinstatement phases) and in the open field test to study effective doses of METH, FEN, or LEV, or ineffective doses of METH+FEN or METH+LEV in combination.

RESULTS

METH and LEV, at 1mg/kg METH each, and 30µg/kg FEN produced CPP. Extinction to METH- or LEV-induced CPP occurred after eight saline injections, but it took 8-26 sessions to extinguish FEN-induced CPP. A challenge dose of 0.5mg/kg METH reinstated CPP. The same occurred with 15µg/kg FEN but not with 0.5 or 1mg/kg LEV. Training animals with ineffective doses of METH (0.01mg/kg) combined with either FEN (0.3µg/kg) or LEV (0.01mg/kg) produced CPP. Sub-effective doses of METH or FEN alone did not induce reinstatement after extinction. However, animals challenged with LEV, METH+FEN, or METH+LEV mixtures did it. Combining FEN (3µg/kg) with 0.1mg/kg METH increased locomotor activity.

CONCLUSION

Ineffective FEN and LEV doses mixed with METH produce effects larger than would be expected based on the effects of either drug alone. This outcome suggests a supra-additive interaction, which could increase the risk of developing a METH use disorder.

Xylazine potentiates the lethal but not the rewarding effects of fentanyl in mice

BACKGROUND

Fentanyl is commonly laced with xylazine. People who use this combination report heightened effects, but it also increases death risk. Although no medication has been approved to counteract overdoses produced by fentanyl and xylazine, naloxone is frequently used. This paper studies the preclinical rewarding and lethal effects of fentanyl combined with xylazine and the efficacy of yohimbine or naloxone to prevent death.

METHODS

Male Swiss Webster mice were treated with (in mg/kg, i.p.) xylazine (0.3, 1, 3, or 5.6), fentanyl (0.01, 0.3, or 0.1), or 1 xylazine plus 0.01 (non-effective) or 0.1 (effective) fentanyl doses during the conditioned-place preference (CPP) test. In addition, independent groups received (in mg/kg, i.p.): xylazine (31.6, 60, 74.2, or 100), fentanyl (3.1 or 10), or both substances at two doses: 31.6 xylazine + 3.1 fentanyl, or 60 xylazine + 10 fentanyl to analyze lethal effects. We determined whether yohimbine or naloxone (each medication tested at 10 or 30mg/kg) could prevent the lethality produced by fentanyl/xylazine combinations. Female mice were also tested in key experiments.

RESULTS

Xylazine neither induced CPP nor altered fentanyl's rewarding effects. In contrast, lethality was potentiated when fentanyl was combined with xylazine. Naloxone, but not yohimbine, effectively prevented the lethality of the fentanyl/xylazine combinations.

CONCLUSIONS

At the doses tested, xylazine does not increase the rewarding effect of fentanyl on the CPP in male mice but potentiates the risk of fatal overdose in male and female mice. A high naloxone dose prevents death induced by coadministration of fentanyl and xylazine in both sexes.

Analysis of umbilical cord tissue as an indicator of in utero exposure to toxic adulterating substances

In utero drug exposure is a significant public health threat to the well-being and normal development of the neonate. Recently, testing of umbilical cord tissue (UCT) has been employed to measure illicit drug exposure, as drugs used by the mother during the third trimester may be retained in the UCT. Focus has also been given to potential adverse health effects among drug users, resulting from exposure to pharmacologically active adulterants and cutting agents in the street drug supply. The in utero effects of these substances have not been well studied in humans, nor has their presence been demonstrated as a means for assessing adverse health effects in the neonate. Here, we describe the application of a novel test method to analyze UCT for the presence of more than 20 common adulterating/cutting substances via LC/Q-TOF. In total, 300 de-identified UCT samples were analyzed-all had previously tested positive for cocaine or opiates. Generally, the positivity rates of individual compounds were similar between the Cocaine and Opiates Subgroups, apart from levamisole, xylazine, dipyrone (metabolites), and promethazine. Many of the adulterants used in the street drug supply do have legitimate medicinal/therapeutic uses, including several of the compounds most frequently detected in this study. Caffeine and lidocaine were the most frequently identified compounds both individually (>70% each) and in combination with each other. Alternatively, levamisole, an adulterant with no legitimate therapeutic use, was present in 12% of cases. Importantly, this data demonstrates that the detection of traditional drugs of abuse may serve as indicators of potential in utero exposure to toxic adulterating substances during gestation. While there is cause for concern with respect to any unintentional drug exposure, illicit drug use during pregnancy, including uncontrolled dosing, poly-adulterant consumption, and the interactions of these drug mixtures, produces a significant public health threat to the neonate which warrants further study.

Co-administration of morphine and levamisole increases death risk, produces neutropenia and modifies antinociception in mice

Levamisole is a veterinary anthelmintic drug and a common adulterant of misused drugs. This study analyses the lethal, antinociceptive and haematological effects produced by acute or repeated levamisole administration by itself or combined with morphine. Independent groups of male Swiss Webster mice were i.p. injected with 100 mg/kg morphine, 31.6 mg/kg levamisole (lethal doses at 10%, LD₁₀ ) or the same doses combined. Naloxone pretreatment (10 mg/kg, i.p.) prevented morphine-induced death, as did 2.5 mg/kg, i.p. mecamylamine with levamisole. Co-administration of levamisole and morphine (Lvm + Mor) increased lethality from 10% to 80%. This augmented effect was prevented by 30 mg/kg, i.p. naloxone and reduced with 10 mg/kg naloxone plus 2.5 mg/kg, i.p. mecamylamine. In independent groups of mice, 17.7 mg/kg, i.p. levamisole antagonized the acute morphine's antinociceptive effect evaluated in the tail-flick test. Repeated 17.7 mg/kg levamisole administration (2×/day/3 weeks) did not affect tolerance development to morphine (10 mg/kg, 3×/day/1 week). Blood samples obtained from mice repeatedly treated with levamisole showed leukopenia and neutropenia. Morphine also produced neutropenia, increased erythrocyte count and other related parameters (e.g. haemoglobin). Lvm + Mor had similar effects on leukocyte and neutrophil counts to those seen with levamisole only, but no erythrocyte-related alterations were evident. Blood chemistry analysis did not indicate liver damage but suggested some degree of electrolyte balance impairment. In conclusion, Lvm + Mor increased death risk, altered morphine-induced antinociceptive effects and produced haematologic abnormalities. The importance of studying combinations of drugs of abuse lies in the fact that drug users frequently combine drugs, which are commonly adulterated.

Qualitative LC/Q-TOF Analysis of Umbilical Cord Tissue via Data-Dependent Acquisition as an Indicator of In Utero Exposure to Toxic Adulterating Substances

Toxic adulterants are drug or chemical agents used to add bulk volume to traditional drugs of abuse such as cocaine, and heroin. These cutting agents include levamisole, metamizole, noxiptillin, phenacetin, and xylazine as well as common legal drugs such as acetaminophen, caffeine, diphenhydramine, lidocaine, quinine, quetiapine, and tramadol. Because they possess pharmacological activity they result in exposure of the user, but also in the case of pregnant women, the developing fetus, to potential drug toxicity. We describe the development, validation, and implementation of a rapid (48 second sample-to-sample) test based on a qualitative data-dependent liquid chromatography-quadrupole time of flight mass spectrometry (LC/Q-TOF) method for the analysis of toxic adulterating substances in umbilical cord tissue (UCT) samples. The method provides a means of studying potential in utero exposure to these agents. Library spectra comparison at 3 different collision energies was used in conjunction with retention time and accurate mass to identify these substances in UCT. Analytically based reporting limits were established to determine positivity rates of adulterants in UCT utilizing a standard addition approach. The method was applied to authentic cocaine and opioid positive UCT's to screen for toxic adulterants. There were a total of 82 potential adulterant positives found in a 30-sample cohort of authentic UCT samples, with an average of 2.7 substances per case. Lidocaine was the predominant finding followed by caffeine, and diphenhydramine all of which could result from non-illicit drug exposure, however, there were positives for levamisole, phenacetin, noxiptillin, and xylazine none of which are approved in the United States for human therapeutic use. This initial set of data established a preliminary positivity rate of potentially toxic adulterants in UCT samples positive for cocaine or opioid use.

Inherent Dangers of Using Non-US Food and Drug Administration-Approved Substances of Abuse

Use of US Food and Drug Administration-approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.

Increasing Substance Use Disorder Treatment Professionals Knowledge: The Child Intervention for Living Drug-free (CHILD) Curriculum

BACKGROUND

A worldwide and ever-growing population of children are using psychoactive substances. To slow this problem, the Child Intervention for Living Drug-Free (CHILD) Curriculum was created to train treatment providers on how to screen, assess, and treat children between the ages of 4-12 years of age exposed to or actively using psychoactive substances. The purpose of the present project was to evaluate the extent to which completion of a six-session training of the six courses of the CHILD Curriculum met the objective of increasing the participants' knowledge of the Curriculum's approach to treating children for substance use problems.

METHODS

71 participants from Africa, Asia, and South America were invited for training and 100% accepted the invitation. Trainees completed an in-person small-group course, occurring over 32 days and comprising 256 total hours. During the CHILD Curriculum training, they completed six separate, 20-item, multiple choice knowledge assessment measures, one for each of the six courses comprising the Curriculum.

RESULTS

Significant (ps<.001) improvement in knowledge in each course was associated with a multivariate measure of strength of the relationship that indicated the change was substantial for five courses (R²s>.5) and moderate for a sixth course. Percentage change from baseline varied from a low of 17% to a high of 63%.

CONCLUSION

The CHILD Curriculum provides a useful educational framework to ensure knowledge gains by trainees. This curriculum content and evaluation provides a framework for future training of providers to pre-adolescent children who use psychoactive substances or are at risk for such use.

Diuretic lounge and the impact on hospital admissions for treatment of decompensated heart failure

BACKGROUND

Heart failure is a prevalent condition associated with frequent and costly hospital admissions. Hospitalizations are primarily related to worsening fluid retention and often require admission for decongestion with intravenous diuretics.

OBJECTIVE

To assess the safety of an outpatient intravenous diuresis service for heart failure patients, and its impact on emergency admissions and the cost of treatment.

METHODS

We conducted a prospective observational cohort registry study on patients referred to the diuretic lounge at our acute hospital between May 2017 and April 2018.

RESULTS

We analysed 245 patients treated in the diuretic lounge, of which 190 (77.6%) avoided hospitalization or any adverse events during the 60 days of follow up (77.6% vs. 22.4%; P < 0.001). The diuretic lounge service resulted in a significant decrease in emergency heart failure admissions compared to the previous 12 months (823 vs. 715 per annum; 68.6 ± 10.1 vs. 59.6 ± 14 per month; P = 0.04), and a numerical reduction in readmission rates (17.3% vs. 16.2%). The 13.1% decrease in admissions lead to financial savings of £315 497 per annum and £2921 per admission avoided. During the same time period, at the other acute hospital site in our trust, where no diuretic lounge service is available, the number of admissions did not significantly change (457 vs. 450 per annum; 37.5 ± 7.0 vs. 38.1 ± 7.6 per month; P = 0.81).

CONCLUSION

Ambulatory administration of intravenous diuretics reduces emergency admissions and is a safe and cost-effective alternative to treat acute decomposition in heart failure patients.

Implementation and Evaluation of a Psychoactive Substance Use Intervention for Children in Afghanistan: Differences Between Girls and Boys at Treatment Entry and in Response to Treatment

Psychoactive substance use among children in Afghanistan is an issue of concern. Somewhere around 300,000 children in the country have been exposed to opioids that either parents directly provided to them or by passive exposure. Evidence-based and culturally appropriate drug prevention and treatment programs are needed for children and families. The goals of this study were to: (1) examine lifetime psychoactive substance use in girls and boys at treatment entry; and (2) examine differential changes in substance use during and following treatment between girls and boys. Children ages 10-17 years old entering residential treatment were administered the Alcohol, Smoking and Substance Involvement Screening Test for Youth (ASSIST-Y) at pre- and post-treatment, and at three-month follow-up. Residential treatment was 45 days for children and 180 days for adolescents and consisted of a comprehensive psychosocial intervention that included education, life skills, individual and group counseling and, for older adolescents, vocational skills such as embroidery and tailoring. Girls and boys were significantly different regarding lifetime use of five substances at treatment entry, with girls less likely than boys to have used tobacco, cannabis, stimulants, and alcohol, and girls more likely than boys to have used sedatives. Differences between boys and girls were found for past-three-month use of four substances at treatment entry, with girls entering treatment with higher past-three-month use of opioids and sedatives, and boys with higher past-three-month use of tobacco, cannabis, and alcohol. Change over the course of treatment showed a general decline for both girls and boys in the use of these substances. Girls and boys in Afghanistan come to treatment with different substance use histories and differences in past-three-month use. Treatment of children for substance use problems must be sensitive to possible differences between girls and boys in substance use history.

The CHILD Intervention for Living Drug-free Comprehensive Assessment of Risk, Resilience, and Experience (CHILD CARRE) Measure: Initial Findings

This paper summarizes the development and evaluation of an assessment instrument for children ages 7-12. The CHILD CARRE measure is a semi-structured interview with 7 domains. Children from the USA and Argentina (N=134) completed baseline and follow-up assessments. Substance use occurred at an average age of 8. Almost 33% of the children were taking medications for medical issues, more than 50% of them said that medical problem gets in the way of doing things they like to to do and almost 64% of the children stated that they would like to feel better. On average, children completed third grade in school, 56% of them knew how to read and 26% of the children started making money at age 8. Most children (74%) saw someone drunk or high and 23% of children reported alcohol or psychoactive substance use. Among these children using substances, such substance use occurred at an average age of 8, and in the past 30 days they used these substances an average for 5 days. The rating of level of risk on the part of the interviewer placed these children in the "risky" to "very risky" categories. Most children reported seeing their family members smoking (83%) or using alcohol (67%), and 49% reported seeing their family members high on drugs. Few children (10%) had conflicts with the law, while 46% of their family members had legal problems. Some children (30%) reported having serious problems getting along with family members, neighbors, or friends. These results suggest that this measure can serve as the first comprehensive measure to assess multiple life domains for young children at risk for or using psychoactive substances.

Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere.

TRIAL REGISTRATION

NCT02722382.

Hemodialysis Clinic Social Networks, Sex Differences, and Renal Transplantation

This study describes patient social networks within a new hemodialysis clinic and models the association between social network participation and kidney transplantation. Survey and observational data collected between August 2012 and February 2015 were used to observe the formation of a social network of 46 hemodialysis patients in a newly opened clinic. Thirty-two (70%) patients formed a social network, discussing health (59%) and transplantation (44%) with other patients. While transplant-eligible women participated in the network less often than men (56% vs. 90%, p = 0.02), women who participated discussed their health more often than men (90% vs. 45.5%, p = 0.02). Patients in the social network completed a median of two steps toward transplantation compared with a median of 0 for socially isolated patients (p = 0.003). Patients also completed more steps if network members were closely connected (β = 2.23, 95% confidence interval [CI] 0.16-4.29, p = 0.03) and if network members themselves completed more steps (β = 2.84, 95% CI 0.11-5.57, p = 0.04). The hemodialysis clinic patient social network had a net positive effect on completion of transplant steps, and patients who interacted with each other completed a similar number of steps.

Contrast-enhanced ultrasound (CEUS) versus computed tomography angiography (CTA) in detection of endoleaks in post-EVAR patients. Are delayed type II endoleaks being missed? A systematic review and meta-analysis

PURPOSE

The purpose of this systematic review is to assess the accuracy of contrast-enhanced ultrasound (CEUS) to computed tomography angiography (CTA) for the detection of endoleaks within EVAR surveillance program.

MATERIAL AND METHODS

A systematic review in Pubmed, Embase and Cochrane database was performed. Articles assessing diagnostic accuracy and comparative modality (CTA vs. CEUS) for endoleaks in adult patients within surveillance programs were retrieved. Methodological assessment was performed, using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tools. The sensitivity and specificity of data were extracted and statistical analysis was performed using MetaDiSc version 1.4.

RESULTS

Eight articles were found eligible (n = 454 patients). The pooled sensitivity of CEUS at detecting endoleak is 0.914 (CI 0.866-0.949) and pooled specificity is 0.782 (CI 0.741-0.820).

CONCLUSION

The CEUS with its dynamic nature and longer scanning window demonstrated to be a highly sensitive modality for endoleak detection in comparison to CTA in delayed endoleaks type II.

The feasibility of audiologists removing earwax

Although cerumen management (CM) is routinely performed by audiologists in some countries, this is currently not the case in the Republic of Ireland. This study involved surveying the opinions of Audiologists and Ear Nose and Throat specialists (ENTs) in relation to audiologists conducting CM. In total, 20 ENT Consultants (29%) and 51 audiologists (64%) in the public services responded to an online survey. There was agreement that CM should be within audiologists' remit. However, with regard to risk, opinions were significantly different, with 15 ENTs (75%), compared to 14 audiologists (27%), in agreement that CM management by audiologists was more risky to patients. Nevertheless, 62 respondents (87%) supported future CM training for audiologists. The. overall similarities of opinion between the two groups contrasted to previous studies that reported strong opposition from ENTs with regard to audiologists managing earwax.

Gender differences in Afghan drug-abuse treatment: an assessment of treatment entry characteristics, dropout, and outcomes

OBJECTIVE

The current study examines gender differences in drug-abuse treatment (DAT) entry, dropout, and outcomes in seven DAT centers in Afghanistan. This is the first study to examine gender differences in DAT programming in Afghanistan.

DESIGN

A prospective cohort design of 504 women and men in seven DAT centers in Afghanistan was used in this study and the analyses examined whether gender differences exist for patients (1) at treatment entry, (2) at treatment dropout, and (3) for treatment outcomes.

RESULTS

Gender differences were found at baseline for patient characteristics, drug use, crime, and social and occupational functioning. Results showed a trend that women remained in treatment longer than men. Looking at gender differences in treatment success, results showed greater reductions in drug use and crime, and greater social functioning among women.

CONCLUSION

Results provide preliminary evidence for potential treatment success of women-tailored DAT programming in Afghanistan. Results also indicate that DAT appears to be successful among Afghan men; however, lower positive outcomes for men when compared to women suggest that more efforts should focus on tailoring DAT programming to the specific needs of Afghan men as well. Study limitations are addressed, and important policy implications are discussed.

Drug use and treatment success among gang and non-gang members in El Salvador: a prospective cohort study

Background

This article focuses on examining drug abuse treatment (DAT) in El Salvador highlighting gang vs. non-gang membership differences in drug use and treatment outcomes.

Methods

Cross-sectional and prospective cohort designs were employed to examine the study aims. The 19 centers that met the study’s inclusion criteria of one year or less in planned treatment offered varying treatment services: individual, group, family, and vocational therapy, dual diagnosis treatment, psychological testing, 12-step program, and outreach and re-entry aftercare. Most directors describe their treatment approach as “spiritual.” Data were collected from 625 patients, directors, and staff from the 19 centers at baseline, of which 34 patients were former gang members. Seventy-two percent (72%) of the former patients (448) were re-interviewed six-months after leaving treatment and 48% were randomly tested for drug use.

Results

Eighty-nine percent (89%) of the DAT patients at baseline were classified as heavy alcohol users and 40% were using illegal drugs, i.e., crack, marijuana, cocaine, tranquilizers, opiates, and amphetamines. There were large decreases after treatment in heavy alcohol and illegal drug use, crime, and gang related risk activities. Gang members reported illegal drug use, crime, and gang related risk activity more than non-gang members, yet only 5% of the study participants were gang members; further, positive change in treatment outcomes among gang members were the same or larger as compared to non-gang members.

Conclusions

Alcohol use is the drug of choice among DAT patients in El Salvador with gang member patients having used illegal drugs more than non-gang members. The study shows that DAT centers successfully reduced the use of illegal drugs and alcohol among gang and non-gang members. Although our study could not include a control group, we believe that the DAT treatment centers in El Salvador contributed to producing this treatment success among former patients. These efforts should be continued and complemented by funding support from the Salvadoran government for DAT centers that obtain certification. In addition, tailored/alternative treatment modalities are needed for gang members in treatment for heavy drinking.

Evaluation of the therapeutic community treatment model in Thailand: policy implications for compulsory and prison-based treatment

This study, conducted in 2005 to 2007, presents results that are based on a proscriptive cohort design. The sample consisted of 769 residents in 22 drug user treatment programs who stayed in treatment for at least 30 days to one year; 510 former residents (66%) from 21 programs (95%) were interviewed again at a 6-month post-treatment follow-up assessment. A majority of the participants were male, lived with family or relatives, had completed only primary school, and had a full-time or a part-time job prior to entering treatment. The participating therapeutic community (TC) programs were a mixture of volunteer, compulsory-probation, and prison-based programs. In-person interview data and urine testing showed that the self-reported drug use prevalence rates are reliable. The results show large positive treatment effects on 30-day and 6-month illegal drug use and small to medium effects on the severity of alcohol use and related problems. A multilevel regression analysis suggests that residents' reduced stigma, adaptation of the TC model, and frequency of alcohol and drug use-related consequences partially predict treatment success. Study limitations and policy implications are discussed.

Examining human rights and mental health among women in drug abuse treatment centers in Afghanistan

Denial of human rights, gender disparities, and living in a war zone can be associated with severe depression and poor social functioning, especially for female drug abusers. This study of Afghan women in drug abuse treatment (DAT) centers assesses (a) the extent to which these women have experienced human rights violations and mental health problems prior to entering the DAT centers, and (b) whether there are specific risk factors for human rights violations among this population. A total of 176 in-person interviews were conducted with female patients admitted to three drug abuse treatment centers in Afghanistan in 2010. Nearly all women (91%) reported limitations with social functioning. Further, 41% of the women indicated they had suicide ideation and 27% of the women had attempted suicide at least once 30 days prior to entering the DAT centers due to feelings of sadness or hopelessness. Half of the women (50%) experienced at least one human rights violation in the past year prior to entering the DAT centers. Risk factors for human rights violations among this population include marital status, ethnicity, literacy, employment status, entering treatment based on one’s own desire, limited social functioning, and suicide attempts. Conclusions stemming from the results are discussed.

Smoking among males in the UK Armed Forces: changes over a seven year period

OBJECTIVES

We assessed socio-demographic and military factors associated with smoking among males in the UK Armed Forces; made comparisons with the general population; and, tested the hypothesis that smoking has declined in the Armed Forces.

METHODS

Using data from two cross-sectional studies (conducted in 1998 and 2004), we examined the patterns of smoking among regular male UK Service personnel aged 20-49 years and made comparisons with general population data from England, Scotland and Wales.

RESULTS

In 2004, the prevalence of smoking among military males aged 20-49 years was 30% (n=2276), compared to 33% within the general population. Among current smokers, the mean number of cigarettes smoked per day was 15 for the military and 14 for the general population. The prevalence of smoking has decreased in lower ranks between 1998 and 2004 by 5.1% in 20-24 year olds to 6.3% in 35-49 year olds. These decreases are similar to those seen within those in the routine, manual or intermediate socio-economic group.

CONCLUSIONS

Smoking among males in the UK military is associated with similar factors to those in the general population. As these factors are clustered in younger personnel, policies to decrease smoking should be targeted at younger recruits.

Therapeutic community drug treatment success in Peru: a follow-up outcome study

Background

The purpose of this study was to assess the impact of drug abuse treatment in Peru that used the therapeutic community (TC) model. Program directors and several staff members from all study treatment facilities received two to eight weeks of in-country training on how to implement the TC treatment model prior to the follow-up study.

Methods

This outcome study involved 33 TC treatment facilities and 509 former clients in Lima and other cities in five providences across Peru. A retrospective pre-test (RPT) follow-up design was employed in which 30-day use of illegal drugs and alcohol to intoxication was measured at baseline retrospectively, at the same time of the six-month follow-up. In-person interview data were collected from directors of 73 percent of the eligible TC organizations in January and February 2003 and from former 58 percent of the eligible TC former clients between October 2003 and October 2004. Drug testing was conducted on a small sample of former clients to increase the accuracy of the self-reported drug use data.

Results

Medium to large positive treatment effects were found when comparing 30-day illegal drug and alcohol use to intoxication before and six months after receiving treatment. As a supplemental analysis, we assumed the 42 percent of the former clients who were not interviewed at the six month assessment had returned to drugs. These results showed medium treatment effects as well. Hierarchical Generalized Linear Modeling (HGLM) results showed higher implementation fidelity, less stigma after leaving treatment, and older clients, singly or in combination are key predictors of treatment success.

Conclusion

This study found that former clients of drug and alcohol treatment in facilities using the TC model reported substantial positive change in use of illegal drugs and alcohol to intoxication at a six-month follow-up. The unique contribution of this study is that the results also suggest attention should be placed on the importance of implementing the TC drug abuse treatment model with fidelity. Further, the results strongly suggest that TC drug abuse treatment programs should incorporate follow-up activities that attempt to neutralize community negative reactions (perceived stigma) independent of other factors.

Reverse foam sclerotherapy of the great saphenous vein with sapheno-femoral ligation compared to standard and invagination stripping: a prospective clinical series

OBJECTIVES

Comparison of Reverse Foam Sclerotherapy of the great saphenous vein (GSV) combed with sapheno-femoral junction (SFJ) ligation to standard (Babcock) stripping and invagination (Pin) stripping in a prospective clinical series.

DESIGN

Prospective clinical series.

MATERIALS AND METHODS

90 consecutive limbs of 82 patients with incompetence of the GSV resulting in varicose veins were prospectively randomised into 3 groups of 30, treated by SFJ ligation and either reverse foam sclerotherapy, standard stripping or invagination stripping of the GSV. Outcomes were assessed post-operatively and at 2-weeks follow-up. Peri-operative blood loss (24 hrs), analgesic requirement, bruising and residual varicosities were assessed. Bruising was assessed by both patients and independent assessors using questionnaires.

RESULTS

SFJ ligation plus reverse foam sclerotherapy of the GSV was associated with significantly less blood loss, bruising and post-op discomfort than either of the stripping techniques. (p<0.001, Mann-Whitney)

CONCLUSION

Standard stripping of the GSV and invagination stripping are not associated with major discomfort and problems in the early post-operative period. SFJ ligation and GSV reverse foam sclerotherapy yielded greater patient satisfaction with less post-op bruising and discomfort and reduced analgesic requirements.

Efficacy and tolerability of the new antiepileptic drugs I: treatment of new onset epilepsy: report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society

OBJECTIVE

To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs (AEDs) (gabapentin, lamotrigine, topiramate, tiagabine, oxcarbazepine, levetiracetam, and zonisamide-reviewed in the order in which these agents received approval by the US Food and Drug Administration) in the treatment of children and adults with newly diagnosed partial and generalized epilepsies.

METHODS

A 23-member committee, including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy, evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane library for relevant articles from 1987 until September 2002, with selected manual searches up until 2003.

RESULTS

There is evidence either from comparative or dose-controlled trials that gabapentin, lamotrigine, topiramate, and oxcarbazepine have efficacy as monotherapy in newly diagnosed adolescents and adults with either partial or mixed seizure disorders. There is also evidence that lamotrigine is effective for newly diagnosed absence seizures in children. Evidence for effectiveness of the new AEDs in newly diagnosed patients with other generalized epilepsy syndromes is lacking.

CONCLUSIONS

The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with newly diagnosed epilepsy and identify those seizure types and syndromes where more evidence is necessary.

Efficacy and tolerability of the new antiepileptic drugs II: Treatment of refractory epilepsy: Report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society

OBJECTIVE

To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs (AEDs) (gabapentin, lamotrigine, topiramate, tiagabine, oxcarbazepine, levetiracetam, and zonisamide) in the treatment of children and adults with refractory partial and generalized epilepsies.

METHODS

A 23-member committee including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane library for relevant articles from 1987 until March 2003.

RESULTS

All of the new AEDs were found to be appropriate for adjunctive treatment of refractory partial seizures in adults. Gabapentin can be effective for the treatment of mixed seizure disorders, and gabapentin, lamotrigine, oxcarbazepine, and topiramate for the treatment of refractory partial seizures in children. Limited evidence suggests that lamotrigine and topiramate are also effective for adjunctive treatment of idiopathic generalized epilepsy in adults and children, as well as treatment of the Lennox Gastaut syndrome.

CONCLUSIONS

The choice of AED depends upon seizure and/or syndrome type, patient age, concomitant medications, AED tolerability, safety, and efficacy. The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with refractory epilepsy and identify those seizure types and syndromes where more evidence is necessary.

Do local anaesthetics interact with dihydropyridine binding sites on neuronal L-type Ca2+ channels?

We have examined the interaction of procaine, prilocaine, lignocaine, bupivacaine, amylocaine and R(+) and S(-) ropivacaine with L-type voltage-sensitive Ca2+ channels in rat cerebrocortical membranes. Membranes were prepared in Tris HCl 50 mmol litre-1, pH 7.4, by homogenization and centrifugation. Binding assays were performed in 1-ml volumes of Tris HCl 50 mmol litre-1, pH 7.4, for 90 min at room temperature using approximately 200 micrograms of protein. Non-specific binding was defined in the presence of nifedipine 10(-5) mol litre-1, and bound and free radioactivity were separated by vacuum filtration. The effects of local anaesthetics were determined by displacement of [3H]PN200-110 (approximately 0.2 nmol litre-1), a radiolabelled 1,4- dihydropyridine (DHP) L-channel antagonist. The concentration of displacer producing 50% displacement was corrected for the competing mass of [3H]PN200-110 to yield the affinity constant, K50. All local anaesthetics displaced [3H]PN200-110 in a dose-dependent manner with a rank order potency of (K50, mmol litre-1) bupivacaine (0.48), amylocaine (0.74), lignocaine (1.09), prilocaine (2.06) and procaine (2.09). Ropivacaine enantiomers did not show stereo-selective displacement, with K50 values of 0.99 and 0.92 mmol litre-1 for R(+) and S(-) ropivacaine, respectively. There was a significant correlation between pK50 and p (octanol:buffer partition coefficient) (r2 = 0.872, P = 0.020), pK50 and p (local anaesthetic potency) (r2 = 0.816, P = 0.036), pK50 and p (relative conduction blocking potency) (r2 = 0.843, P = 0.028) and between pK50 and p (IC50 for inhibition of cardiac output) (r2 = 0.897, P = 0.015). These data suggest that DHP binding sites may be involved in both the mechanism of local anaesthesia and the cardiotoxicity of these agents.

Cardiac resuscitation with percutaneous cardiopulmonary support

Percutaneous cardiopulmonary support (CPS) was initiated in 9 patients to provide haemodynamic stability after failure of conventional resuscitation. 4 patients were in cardiogenic shock and 4 remained in asystole, with 1 in resistant ventricular fibrillation, after cardiac arrest. During CPS for those in cardiogenic shock, the mean intra-arterial pressures ranged from 65 to 100 mm Hg (mean 84), at flow rates of between 3 to 5 l/min (mean 3.9). 2 patients underwent technically successful coronary angioplasty. No patient in this group survived. In the cardiac arrest group, acceptable mean intra-arterial blood pressures were achieved (mean 95, range 90-100 mm Hg) at flow rates of between 2 to 3 l/min (mean 2.6). All 5 subjects underwent technically successful coronary angioplasty whilst on CPS. 4 survived. 2 were alive and well at 12 months follow-up, 1 of whom had returned to work; the third is alive and well at 4 months.

Pseudomonas osteomyelitis of the metatarsal sesamoid. A case report

Osteomyelitis of the metatarsal sesamoid is rare. Few cases of Pseudomonas osteomyelitis have been reported. This report includes a current review of the literature and case report. The difficulty in diagnosis and suggested treatment are discussed.

Modulation of L-phenylalanine ammonia-lyase by pathway intermediates in cell suspension cultures of dwarf French bean (Phaseolus vulgaris L.)

The increase in extractable phenylalanine ammonia-lyase (PAL;EC 4.3.1.5.) activity induced in French bean cell suspension cultures in response to treatment with autoclaved ribonuclease A was inhibited by addition of the phenylpropanoid pathway intermediates cinnamic acid, 4-coumaric acid or ferulic acid. The effectiveness of inhibition was in the order cinnamic acid>4-coumaric acid>ferulic acid. Cinnamic acid also inhibited the PAL activity increase induced by dilution of the suspensions into an excess of fresh culture medium. Addition of low concentrations (<10(-5)M) of the pathway intermediates to cultures at the time of application of ribonuclease gave variable responses ranging from inhibition to 30-40% stimulation of the PAL activity measured at 8 h. Following addition of pathway intermediates to cultures 4-5 h after ribonuclease treatment, rapid increases followed by equally rapid declines in PAL activity were observed. The cinnamic acid-stimulated increase in enzyme activity was unaffected by treatment with cycloheximide at a concentration which gave complete inhibition of the ribonuclease-induced response. However, cycloheximide completely abolished the subsequent decline in enzyme activity. Treatment of induced cultures with α-aminooxy-β-phenylpropionic acid (AOPPA) resulted in increased but delayed rates of enzyme appearance when compared to controls not treated with the phenylalanine analogue. The results are discussed in relation to current views on the regulation of enzyme levels in higher plants.

A selective comparison of psychological, developmental, social, and academic factors among emotionally disturbed children in three treatment settings

This study was undertaken to determine whether there were significant differences among three groups of emotionally disturbed children in Massachusetts: children in private residential schools; children in private day schools; and children in special classes for the emotionally disturbed in public schools. The subjects involved in the study consisted of three groups of children who were evaluated as being emotionally disturbed and whose initial enrollments in the respective programs were accomplished during the 1972 to 1973 school year. This represented 129 children enrolled in private day schools, 72 children enrolled in private residential schools, and 309 children enrolled in public school special classes for the emotionally disturbed. Data for these populations were obtained from the records for each of the children on file at the Massachusetts Department of Education, Division of Special Education. This included data on psychiatric diagnosis, IQ, parental separation, geographical location, family income, family social position, and assessment of the child's physical well-being. In addition, two tests were administered to all subjects: The Rutter Child Behavior Scale was completed by each child's classroom teacher, and the Wide Range Achievement Test was administered by the professional having the responsibility for psychometric testing in the respective school.

Emotionally disturbed children in special schools: an analysis of ratings of disturbed behavior and perceptual handicaps

The relationship between perceptual handicaps and adjustment was studied among 573 emotionally disturbed children from Massachusetts. Little relationship was found between perceptual handicaps and overall adjustment. Antisocial behavior was the most prominent factor related to removal from regular classrooms and placement in special residential and day schools.