Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements

BACKGROUND

Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites.

OBJECTIVE

To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites.

DESIGN

This was a qualitative evaluation based on semi-structured video-based focus groups.

PARTICIPANTS

Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA.

APPROACH

Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes.

KEY RESULTS

Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum.

CONCLUSIONS

Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.

The Effect of Geographic Cohorting of Inpatient Teaching Services on Patient Outcomes and Resident Experience

BACKGROUND

Geographic cohorting is a hospital admission structure in which every patient on a given physician team is admitted to a dedicated hospital unit. Little is known about the long-term impact of this admission structure on patient outcomes and resident satisfaction.

OBJECTIVE

To evaluate the effect of geographic cohorting on patient outcomes and resident satisfaction among inpatient internal medicine teaching services within an academic hospital.

DESIGN AND INTERVENTION

We conducted an interrupted time series analysis examining patient outcomes before and after the transition to geographic cohorting of our 3 inpatient teaching services within a 520-bed academic hospital in November 2017. The study observation period spanned from January 2017 to October 2018, allowing for a 2-month run-in period (November-December 2017).

PARTICIPANTS

We included patients discharged from the inpatient teaching teams during the study period. We excluded patients admitted to the ICU and observation admissions.

MAIN MEASURES

Primary outcome was 6-month mortality adjusted for patient age, sex, race, insurance status, and Charlson Comorbidity Index (CCI) analyzed using a linear mixed effects model. Secondary outcomes included hospital length of stay (LOS), 7-day and 30-day readmission rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and resident evaluations of the rotation.

KEY RESULTS

During the observation period, 1720 patients (mean age 64, 53% female, 56% white, 62% Medicare-insured, mean CCI 1.57) were eligible for inclusion in the final adjusted model. We did not detect a significant change in 6-month mortality, LOS, and 7-day or 30-day readmission rates. HCAHPS scores remained unchanged (77 to 80% top box, P = 0.19), while resident evaluations of the rotation significantly improved (mean overall score 3.7 to 4.0, P = 0.03).

CONCLUSIONS

Geographic cohorting was associated with increased resident satisfaction while achieving comparable patient outcomes to those of traditional hospital admitting models.

Acceptability and Efficacy of the SMARxT Media Literacy Education Program to Counter Pharmaceutical Marketing Influences among Medical Trainees

Background

Evidence-based prescribing (EBP) results in decreased morbidity and reduces medical costs. However, pharmaceutical marketing influences medication requests and prescribing habits, which can detract from EBP. Media literacy, which teaches critical thinking, is a promising approach for buffering marketing influences and encouraging EBP. The authors developed the "SMARxT" media literacy education program around marketing influences on EBP decision-making. The program consisted of six videos and knowledge assessments that were delivered as an online educational intervention through the Qualtrics platform.

Methods

In 2017, we assessed program feasibility, acceptability, and efficacy of enhancing knowledge among resident physicians at the University of Pittsburgh. Resident physicians (n=73) responded to pre-test items assessing prior knowledge, viewed six SMARxT videos, and responded to post-test items. A 6-month follow-up test was completed to quantitatively assess sustained changes in knowledge and to qualitatively assess summative feedback about the program (n=54). Test scores were assessed from pre- to post-test and from pre-test to follow-up using paired-sample t-tests. Qualitative results were synthesized through content analysis.

Results

Proportion of correct knowledge responses increased from pre-test to immediate post-test (31% to 64%, P<0.001) at baseline. Correct responses also increased from pre-test to 6-month follow-up (31% to 43%, P<0.001). Feasibility was demonstrated by 95% of enrolled participants completing all baseline procedures and 70% completing 6-month follow-up. Quantitative measures of acceptability yielded positive scores and qualitative responses indicated participants' increased confidence in understanding and countering marketing influences due to the intervention. However, participants stated they would prefer shorter videos, feedback about test scores, and additional resources to reinforce learning objectives.

Conclusion

The SMARxT media literacy program was efficacious and acceptable to resident physicians. Participant suggestions could be incorporated into a subsequent version of SMARxT and inform similar clinical education programs. Future research should assess program impact on real-world prescribing practices.

A Call to Action: Integration of Buprenorphine Prescribing into the Care of Persons with HIV and Opioid Use Disorder

During the coronavirus disease 2019 (COVID-19) pandemic, we also experienced a worsening opioid overdose epidemic. Untreated opioid use disorder (OUD) in persons with human immunodeficiency virus (HIV) is associated with worse HIV-related outcomes. Buprenorphine is a safe, evidence-based medication for OUD and is effective in reducing opioid craving and overdose and improving outcomes along the HIV care continuum. Despite the longstanding evidence supporting the benefits of buprenorphine, there remains an implementation gap in the uptake of buprenorphine prescribing in HIV care settings. To improve integration of OUD care and HIV primary care, we recommend (1) all HIV clinicians obtain a buprenorphine waiver, (2) teaching on OUD should be integrated into infectious diseases and HIV continuing medical education, and (3) previously validated models of integrated care should be leveraged to urgently expand access to buprenorphine for persons with HIV and OUD.

Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.

Factors Associated with Long-Term Retention in Buprenorphine-Based Addiction Treatment Programs: a Systematic Review

BACKGROUND

The average length of buprenorphine treatment for opioid use disorder is less than 6 months.

OBJECTIVE

We conducted a systematic review to determine what factors were associated with longer retention in buprenorphine treatment.

DESIGN

We searched Medline, Embase, and Cochrane Database of Systematic Reviews in February 2018. Articles were restricted to randomized controlled trials on human subjects, written in English, which contained ≥ 24 weeks of objective data on retention in buprenorphine treatment.

MAIN MEASURES

We assessed whether dose of buprenorphine, treatment setting, or co-administration of behavioral therapy was associated with retention rates.

KEY RESULTS

Over 14,000 articles were identified. Thirteen articles (describing 9 studies) met inclusion criteria. Measures of retention varied widely. Three studies compared doses of buprenorphine between 1 and 8 mg and showed significantly higher rates of retention with higher doses (p values < 0.01). All other studies utilized buprenorphine doses between 8 and 24 mg daily, without comparison. No study found a significant difference in retention between buprenorphine alone and buprenorphine plus behavioral therapy (p values > 0.05). Initiating buprenorphine while hospitalized or within criminal justice settings prior to outpatient treatment programs was significantly associated with retention in buprenorphine treatment (p values < 0.01 respectively).

CONCLUSIONS

Setting of treatment initiation and a higher buprenorphine dose are associated with improved long-term treatment retention. More objective data on buprenorphine treatment programs are needed, including a standardized approach to defining retention in buprenorphine treatment programs.

REGISTRATION

This review was registered with PROSPERO (#CRD42019120336) in March 2019.

Provider perceptions of medication for opioid used disorder (MOUD): A qualitative study in communities with high opioid overdose death rates

BACKGROUND

Medication for Opioid Use Disorder (MOUD) has been shown to be a safe, cost-effective intervention that successfully lowers risk of opioid overdose. However, access to and use of MOUD has been limited. Our objective was to explore attitudes, opinions, and beliefs regarding MOUD among healthcare and social service providers in a community highly impacted by the opioid overdose epidemic.

METHODS

As part of a larger ethnographic study examining neighborhoods in Allegheny County, PA, with the highest opioid overdose death rates, semi-structured qualitative in-person and telephone interviews were conducted with forty-five providers treating persons with opioid use disorders in these communities. An open coding approach was used to code interview transcripts followed by thematic analysis.

RESULTS

Three major themes were identified related to MOUD from the perspectives of our provider participants. Within a variety of health and substance use service roles and settings, provider reflections revealed: (1) different opinions about MOUD as a transition to abstinence or as a long-term treatment; (2) perceived lack of uniformity and dissemination of accurate information of MOUD care, permitting differences in care, and (3) observed barriers to entry and navigation of MOUD, including referrals as a "word-of-mouth insider system" and challenges of getting patients MOUD services when they need it.

CONCLUSIONS

Even in communities hard hit by the opioid overdose epidemic, healthcare providers' disagreement about the standard of care for MOUD can be a relevant obstacle. These insights can inform efforts to improve MOUD treatment and access for people with opioid use disorders.

Impact of intensity of behavioral treatment, with or without medication treatment, for opioid use disorder on HIV outcomes in persons with HIV

BACKGROUND

Persons with HIV (PWH) and opioid use disorder (OUD) can have poor health outcomes. We assessed whether intensity of behavioral treatment for OUD (BOUD) with and without medication for OUD (MOUD) is associated with improved HIV clinical outcomes.

METHODS

We used Veterans Aging Cohort Study (VACS) data from 2008 to 2017 to identify PWH and OUD with ≥1 BOUD episode. We assessed BOUD intensity and ≥6 months of MOUD (methadone or buprenorphine) receipt during the 12 months after BOUD initiation. Linear regression models assessed the association of BOUD intensity and MOUD receipt with pre-post changes in log viral load (VL), CD4 cell count, VACS Index 2.0, antiretroviral treatment (ART) initiation, and ART adherence.

RESULTS

Among 2419 PWH who initiated BOUD, we identified five distinct BOUD intensity trajectories: single visit (39% of sample); low-intensity, not sustained (37%); high-intensity, not sustained (9%); low-intensity, sustained (11%); and high-intensity, sustained (5%). MOUD receipt was low (17%). Among 709 PWH not on ART at the start of BOUD, ART initiation increased with increased BOUD intensity (p < 0.01). Among 1401 PWH on ART at the start of BOUD, ART adherence improved more in higher-intensity BOUD groups (p < 0.01). VL, CD4 count and VACS Index 2.0 did not differ by BOUD or ≥6 months of MOUD treatment.

CONCLUSION

Among PWH and OUD who initiated BOUD, higher intensity BOUD was associated with improved ART initiation and adherence, but neither BOUD alone nor BOUD plus ≥6 months MOUD was associated with improvements in VL, CD4 count or VACS Index 2.0.

Free Clinic Patients' Perceptions and Barriers to Applying for Health Insurance After Implementation of the Affordable Care Act

Despite implementation of the Affordable Care Act (ACA), many Americans remain uninsured and receive care in free clinics. It is unknown what free clinic attendees in Pennsylvania know about health insurance expansion or what they perceive as barriers in enrolling in health insurance. The objective of this study was to assess the perceptions and experiences of free clinic patients from southwestern Pennsylvania when applying for health insurance after implementation of the ACA. We designed and implemented a survey of patients at three free clinics within Allegheny County, Pennsylvania from September 2016 to February 2017. Our survey included 22-items, 7 sociodemographic questions and 15 questions regarding the patient's health status and their perspectives related to obtaining health insurance. Data was obtained from 203 patient surveys; 110 (55.3%) of the respondents were men and 99 (48.8%) were African American. There were 48 respondents (24.1%) who did not report any income at the time of the study, and of those that did report an income, 92 (46.2%) respondents reported an income below 133% of the federal poverty level. The main barriers patients faced when applying for health insurance were: (1) lack of knowledge about health insurance (n = 127, 58.1%), (2) cost of health coverage (n = 85, 41.9%), (3) lack of resources (n = 83, 40.4%), and (4) lack of enrollment documentation (n = 43, 23.8%). Significant work is needed to better educate patients about their eligibility and options for health insurance. Free clinics can play a key role in eliminating barriers to health insurance enrollment.

Impact of COVID-19 on Recovered Athletes Returning to Competitive Play in the NBA "Bubble"

BACKGROUND

The global pandemic caused by COVID-19 has had far-reaching implications for the world of professional sports. The National Basketball Association (NBA) suspended active regular season play in 2020 after a player tested positive for SARS-CoV-2. No previous studies have examined the impact of COVID-19 on return to play in the NBA.

PURPOSE/HYPOTHESIS

The purpose of this study was to examine performance measures for NBA players who had recovered from COVID-19 and returned to play in the NBA bubble. We hypothesized that these athletes would play fewer minutes and have decreased performance statistics compared with performance during the 2019-2020 regular season prior to the lockdown and with career averages.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

NBA players positive for SARS-CoV-2 who played in both the 2019-2020 regular season and the NBA bubble were identified. Data collected included player demographics and player performance statistics.

RESULTS

A total of 20 players were included in the study. Players who had recovered from COVID-19 played significantly fewer minutes per game in the NBA bubble (25.8 vs 28.7; P = .04) and made fewer field goals per game (4.6 vs 5.4; P = .02) compared with the season prior to shutdown. While NBA bubble players demonstrated slight decreases in averages for points (P = .06), rebounds (P =.13), assists (P = .23), steals (P = .30), and blocks (P = .71) per game, these were not statistically significant. Aside from an increase in made free throws per game during the bubble (3.3 vs 2.8; P = .04), player performance was not significantly different from career averages.

CONCLUSION

For players who tested positive for SARS-CoV-2 prior to playing in the NBA bubble, the current study demonstrated that despite playing significantly fewer minutes per game, performance was not statistically different from either their pre-COVID 2019-2020 level of play or from their career averages.

Tet1 Isoforms Differentially Regulate Gene Expression, Synaptic Transmission, and Memory in the Mammalian Brain

The dynamic regulation of DNA methylation in postmitotic neurons is necessary for memory formation and other adaptive behaviors. Ten-eleven translocation 1 (TET1) plays a part in these processes by oxidizing 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC), thereby initiating active DNA demethylation. However, attempts to pinpoint its exact role in the nervous system have been hindered by contradictory findings, perhaps due in part, to a recent discovery that two isoforms of the Tet1 gene are differentially expressed from early development into adulthood. Here, we demonstrate that both the shorter transcript (Tet1S ) encoding an N-terminally truncated TET1 protein and a full-length Tet1 (Tet1FL ) transcript encoding canonical TET1 are co-expressed in the adult mouse brain. We show that Tet1S is the predominantly expressed isoform and is highly enriched in neurons, whereas Tet1FL is generally expressed at lower levels and more abundant in glia, suggesting their roles are at least partially cell type-specific. Using viral-mediated, isoform and neuron-specific molecular tools, we find that the individual repression of each transcript leads to the dysregulation of unique gene ensembles and contrasting changes in basal synaptic transmission. In addition, Tet1S repression enhances, while Tet1FL impairs, hippocampal-dependent memory in male mice. Together, our findings demonstrate that each Tet1 isoform serves a distinct role in the mammalian brain.SIGNIFICANCE STATEMENT In the brain, activity-dependent changes in gene expression are required for the formation of long-term memories. DNA methylation plays an essential role in orchestrating these learning-induced transcriptional programs by influencing chromatin accessibility and transcription factor binding. Once thought of as a stable epigenetic mark, DNA methylation is now known to be impermanent and dynamically regulated, driving neuroplasticity in the brain. We found that Tet1, a member of the ten-eleven translocation (TET) family of enzymes that mediates removal of DNA methyl marks, is expressed as two separate isoforms in the adult mouse brain and that each differentially regulates gene expression, synaptic transmission and memory formation. Together, our findings demonstrate that each Tet1 isoform serves a distinct role in the CNS.

Internal Medicine Resident Perceptions of Patients with Substance Use Disorder After Attending a Mutual Support Group Meeting

BACKGROUND

Mutual support groups (MSGs) are support systems for patients with substance use disorders (SUDs), yet medical residents lack awareness in the role MSGs play in addiction treatment.

AIM

We developed an educational intervention to expose residents to MSGs and improve attitudes toward patients with SUD.

SETTING

The study took place from October 2017 to March 2018 within a large academic medical center.

PARTICIPANTS

First- to third-year internal medicine residents participated.

PROGRAM DESCRIPTION

Residents attended a MSG meeting. They completed surveys pre- and post-meeting and attended a focus group debrief session. Focus group transcripts were coded and thematically analyzed.

PROGRAM EVALUATION

Sixty-eight residents participated in the curriculum, 54 attended the focus group and 47 completed the pre- and post-survey. Qualitative themes included (1) appreciation for the sense of community at meetings, (2) improved perspective taking of patients with SUDs, (3) concern regarding religion, and (4) improved confidence in MSG referrals. Post-intervention, residents had more positive attitudes toward patients with SUD (p < 0.05 for 9 of 14 questions) and toward MSGs (p < 0.05 for 2 of 4 questions).

DISCUSSION

Implementing an educational intervention on MSGs gives residents an experience that impacts attitudes toward patients with SUD and confidence with MSG referrals.

Would You Be Surprised If This Patient Died This Year? Advance Care Planning in Substance Use Disorders

Primary care physicians are increasingly incorporating screening tools for substance use disorders (SUDs) and referral to treatment into their practice. Despite efforts to provide access to treatment, patients with SUDs remain at an increased risk of mortality, both from overdose and from general medical conditions. Advance care planning (ACP) is recommended for patients with chronic, progressive medical conditions such as malignancies or heart failure. Though SUDs are widely acknowledged to be chronic diseases associated with an increased risk of mortality, there has been little discussion on ACP in this population. ACP is a discussion regarding future care, often including selection of a surrogate decision-maker and completion of an advanced directive. ACP has been associated with better quality of end-of-life and care more consistent with patient preferences. Studies in other vulnerable populations have shown that marginalized and high-risk individuals may be less likely to receive ACP. Similarly, patients with SUDs may employ different decision-makers than that defined by law (i.e., friend vs. family member), increasing the importance of discussing patient values and social structure. Physicians should routinely conduct ACP conversations with patients with SUDs, especially those with chronic, progressive medical conditions and/or severe, uncontrolled substance use disorders.

Histopathologic delineation of the transition zone in short-segment Hirschsprung disease

Failure to completely resect the transition zone (TZ) between aganglionic and neuroanatomically normal bowel ("TZ pull-through") is considered one reason for postoperative obstructive symptoms in Hirschsprung disease (HD). Despite years of study, the proximal boundary of the TZ remains nebulous, complicated by discordant, often subjective, histopathologic definitions. In order to objectively delineate the TZ, transverse sections at 1 cm intervals from the rectums of 9 non-HD autopsy subjects and resections from 15 infants with short-segment HD were immunostained with Hu (ganglion cell bodies) and glucose transporter 1 (Glut1) (perineurium of extrinsic nerves), and 6 putative features of TZ were examined: (1) aganglionosis of ≥1/8th circumference; (2) myenteric or submucosal hypoganglionosis; (3) hypertrophic submucosal nerves; (4) Glut1+ submucosal innervation; (5) submucosal hyperganglionosis; and (6) "ectopic" ganglia in lamina propria, muscularis propria, or serosa. In non-HD controls, Glut1+ submucosal innervation, hypertrophic nerves, partial circumferential aganglionosis, and hypoganglionosis were absent or restricted to the distal 2 cm. In contrast, all 6 neuropathologic features of TZ were identified proximal to the aganglionic segment in the majority of HD resections, but the length of the TZ ranged from 0 to 12 cm, depending on which neuropathologic feature was considered. Excluding submucosal hyperganglionosis and ectopic ganglia, the TZ was generally ≤5 cm. Many features of TZ cannot be excluded intraoperatively with a biopsy or a full-circumference frozen section. However, partial circumferential aganglionosis, severe myenteric hypoganglionosis, and hypertrophic submucosal nerves can, and probably should, be assessed in full-circumference frozen sections of the proximal resection margin, to reduce the likelihood of TZ pull-through.

Mechanical properties and structure of the biological multilayered material system, Atractosteus spatula scales

During recent decades, research on biological systems such as abalone shell and fish armor has revealed that these biological systems employ carefully arranged hierarchical multilayered structures to achieve properties of high strength, high ductility and light weight. Knowledge of such structures may enable pathways to design bio-inspired materials for various applications. This study was conducted to investigate the spatial distribution of structure, chemical composition and mechanical properties in mineralized fish scales of the species Atractosteus spatula. Microindentation tests were conducted, and cracking patterns and damage sites in the scales were examined to investigate the underlying protective mechanisms of fish scales under impact and penetration loads. A difference in nanomechanical properties was observed, with a thinner, stiffer and harder outer layer (indentation modulus ∼69 GPa and hardness ∼3.3 GPa) on a more compliant and thicker inner layer (indentation modulus ∼14.3 GPa and hardness ∼0.5 GPa). High-resolution scanning electron microscopy imaging of a fracture surface revealed that the outer layer contained oriented nanorods embedded in a matrix, and that the nanostructure of the inner layer contained fiber-like structures organized in a complex layered pattern. Damage patterns formed during microindentation show complex deformation mechanisms. Images of cracks identify growth through the outer layer, then deflection along the interface before growing and arresting in the inner layer. High-magnification images of the crack tip in the inner layer show void-linking and fiber-bridging exhibiting inelastic behavior. The observed difference in mechanical properties and unique nanostructures of different layers may have contributed to the resistance of fish scales to failure by impact and penetration loading.

Transitional zone pull through: surgical pathology considerations

Incomplete resection of the transitional zone (TZ) between histologically normal and aganglionic bowel in Hirschsprung disease is a putative cause of postoperative dysmotility. A review of literature indicates that diverse histopathological indexes have been used to define the TZ, and validated and reproducible diagnostic criteria have not been established. As a consequence, the proximal margin of the TZ is difficult to delimit, and the length of the TZ in a given patient depends on the diagnostic criteria used. Seromuscular biopsies are inadequate to exclude TZ, as diagnostic indexes may involve only a portion of the bowel circumference or the submucosa. Most published investigations of postoperative outcome after a TZ pull through (TZPT) conclude that the latter can cause persistent obstructive symptoms, which necessitate reoperation. However, the results of these studies are difficult to translate into clinical practice because most lack appropriate controls, and the overwhelming majority provide inadequate histopathological descriptions for reference at the time of intraoperative frozen section analysis. At present, a conservative approach based on frozen section examination of the entire proximal margin of the resection to exclude obvious subcircumferential aganglionosis (contiguous gap between ganglia of more than one-eighth of the circumference), hypoganglionosis (continuous string of myenteric ganglia comprised of 1 or 2 ganglion cells without surrounding neuropil), or hypertrophic submucosal nerves (>2 nerves with widths ≥40 μm per high-power field) seems prudent. Well-controlled studies to correlate proximal margin histology, especially subtle anatomic or immunohistochemical changes, with postoperative outcome are needed.

Geochemical investigations of metals release from submerged coal fly ash using extended elutriate tests

A storage pond dike failure occurred at the Tennessee Valley Authority Kingston Fossil Plant that resulted in the release of over 3.8 million cubic meters (5 million cubic yards) of fly ash. Approximately half of this material deposited in the main channel of the Emory River, 3.5 km upstream of the confluence of the Emory and Clinch Rivers, Tennessee, USA. Remediation efforts to date have focused on targeted removal of material from the channel through hydraulic dredging, as well as mechanical excavation in some areas. The agitation of the submerged fly ash during hydraulic dredging introduces river water into the fly ash material, which could alter the redox state of metals present in the fly ash and thereby change their sorption and mobility properties. A series of extended elutriate tests were used to determine the concentration and speciation of metals released from fly ash. Results indicated that arsenic and selenium species released from the fly ash materials during elutriate preparation were redox stable over the course of 10d, with dissolved arsenic being present as arsenate, and dissolved selenium being present as selenite. Concentrations of certain metals, such as arsenic, selenium, vanadium, and barium, increased in the elutriate waters over the 10d study, whereas manganese concentrations decreased, likely due to oxidation and precipitation reactions.

Angiotensin II type 2 receptor expression after vascular injury: differing effects of angiotensin-converting enzyme inhibition and angiotensin receptor blockade

It has been suggested that the effects of angiotensin II type 1 receptor (AT1R) blockers are in part because of angiotensin II type 2 receptor (AT2R) signaling. Interactions between the AT2R and kinins modulate cardiovascular function. Because AT2R expression increases after vascular injury, we hypothesized that the effects on vascular remodeling of the AT1R blocker valsartan and the ACE inhibitor benazepril require AT2R signaling through the bradykinin 1 and 2 receptors (B1R and B2R). To test this hypothesis, Brown Norway rats were assigned to 8 treatments (n=16): valsartan, valsartan+PD123319 (AT2R inhibitor), valsartan+des-arg9-[Leu8]-bradykinin (B1R inhibitor), valsartan+HOE140 (B2R inhibitor), benazepril, benazepril+HOE140, amlodipine, and vehicle. After 1 week of treatment, carotid balloon injury was performed. Two weeks later, carotids were harvested for morphometry and analysis of receptor expression by immunohistochemistry and Western blotting. Valsartan and benazepril significantly reduced the intima:media ratio compared with vehicle. Blockade of AT2R, B1R, or B2R in the presence of valsartan prevented the reduction seen with valsartan alone. B2R blockade inhibited the effect of benazepril. Injury increased AT1R, AT2R, B1R, and B2R expression. Treatment with valsartan but not benazepril significantly increased intima AT2R expression 2-fold compared with vehicle, which was not reversed by inhibition of AT2R, B1R, and B2R. Functionally, valsartan increased intimal cGMP levels compared with vehicle, and this increase was inhibited by blocking the AT2R, B1R, and B2R. Results suggest that AT2R expression and increased cGMP represent a molecular mechanism that differentiates AT1R blockers, such as valsartan, from angiotensin-converting enzyme inhibitors like benazepril.

Evaluation of ionic contribution to the toxicity of a coal-mine effluent using Ceriodaphnia dubia

The United States Environmental Protection Agency has defined national in-stream water-quality criteria (WQC) for 157 pollutants. No WQC to protect aquatic life exist for total dissolved solids (TDS). Some water-treatment processes (e.g., pH modifications) discharge wastewaters of potentially adverse TDS into freshwater systems. Strong correlations between specific conductivity, a TDS surrogate, and several biotic indices in a previous study suggested that TDS caused by a coal-mine effluent was the primary stressor. Further acute and chronic testing in the current study with Ceriodaphnia dubia in laboratory-manipulated media indicated that the majority of the effluent toxicity could be attributed to the most abundant ions in the discharge, sodium (1952 mg/L) and/or sulfate (3672 mg/L), although the hardness of the effluent (792 +/- 43 mg/L as CaCO3) ameliorated some toxicity. Based on laboratory testing of several effluent-mimicking media, sodium- and sulfate-dominated TDS was acutely toxic at approximately 7000 microS/cm (5143 mg TDS/L), and chronic toxicity occurred at approximately 3200 microS/cm (2331 mg TDS/L). At a lower hardness (88 mg/L as CaCO3), acute and chronic toxicity end-points were decreased to approximately 5000 microS/cm (3663 mg TDS/L) and approximately 2000 microS/cm (1443 mg TDS/L), respectively. Point-source discharges causing in-stream TDS concentrations to exceed these levels may risk impairment to aquatic life.

Evaluation of ecologically relevant bioassays for a lotic system impacted by a coal-mine effluent, using Isonychia

Many studies investigating the ecotoxicological impacts of industrial effluents on fresh-water biota utilize standardized test species such as the daphnids, Ceriodaphnia dubia, Daphnia magna, and the fathead minnow, Pimephales promelas. Such species may not be the most predictive or ecologically relevant gauges of the responses of instream benthic macroinvertebrates to certain stressors, such as total dissolved solids. An indigenous species approach should be adopted, using a sensitive benthic collector-filterer following development of practical laboratory bioassays. In the Leading Creek Watershed (southeast Ohio), an aggregated approximately 99% reduction in mean mayfly abundance for all impacted sites was observed below a coal-mine effluent with mean specific conductivity (SC) of 8,109 (7,750-8,750) microS cm(-1). The mayfly, Isonychia, was exposed for 7-days to a simulation of this effluent, in lotic microcosms. Based on lowest observable adverse effect concentrations, Isonychia survival was a more sensitive endpoint to SC (1,562 microS cm(-1)) than were 7-day C. dubia survival and fecundity (3,730 microS cm(-1)). Isonychia molting, a potentially more sensitive endpoint, was also examined. Using traditional test species to assess discharges to surface water alone may not adequately protect benthic macroinvertebrate assemblages in systems impaired by discharges high in SC.

Field and laboratory assessment of a coal processing effluent in the Leading Creek Watershed, Meigs County, Ohio

The U.S. Environmental Protection Agency has not recommended water quality criteria (WQC) to protect aquatic life from elevated sodium and sulfate concentrations, such as those associated with the coal-processing effluent of Meigs County Mine #31. This discharge, received by a tributary of the Leading Creek Watershed (SE Ohio), had a mean specific conductivity (SC) of 8,109 (7,750-8,750) microS/cm and total metal concentrations below acute WQC. The mean 48-h LC(50) for Ceriodaphnia dubia in the effluent was 6,713 +/- 99 microS/cm; mean 48-h survival was 44% for study sites downstream of the effluent. The best indicators of impairment used in this study were Ceriodaphnia fecundity, in situ Corbicula fluminea growth, EPT minus Hydropsychidae (richness and relative abundance), and relative Ephemeroptera abundance. Mayflies, reduced by more than 99% below the effluent, were absent from all but the furthest downstream study site. SC was strongly correlated with Corbicula growth (r = -0.9755, p = 0.0009) and EPT minus Hydropsychidae richness (r = -0.8756, p < 0.0001), suggesting the effluent was primarily responsible for biotic impairment. Our results indicated that SC levels, a measure of dissolved solids, in the Leading Creek Watershed that exceeded approximately 3,700 microS/cm impaired sensitive aquatic fauna.

Familial aggregation of nutrient intake and physical activity: results from the San Antonio Family Heart Study

PURPOSE

To evaluate the extent to which levels of physical activity and nutrient intake aggregate in families, and secondarily, to assess the repeatability of these behavioral measures over a 5-year period.

METHODS

Measurements were obtained in a population-based sample consisting of 1364 members of 42 large Mexican American families. Nutrient intake was assessed by a food frequency questionnaire validated for use in this population. Usual level of physical activity was estimated using a 7-day recall questionnaire.

RESULTS

Correlations between baseline (obtained 1992-1995) and follow-up (obtained 1996 to 2000) measures of all behaviors were highly significant (p < 0.001), ranging from 0.24 for % of calories derived from fat to 0.44 for % of calories derived from alcohol. Familial effects, estimated using variance component methods, were stronger when modeled as a genetic heritability than as a shared household effect; as a heritability they accounted for a significant portion of the total variation of all traits (9% for physical activity levels, p < 0.05; and 13-26% for nutrient intake, p < 0.001 for all).

CONCLUSIONS

Measurements of physical activity and dietary behaviors in this population tracked over 5 years, and there was a significant degree of aggregation of these behaviors within families. Understanding the sources of these family effects may facilitate efforts to improve cardiovascular health.

Neurotrophin-3 is increased in skin in human diabetic neuropathy

Neurotrophin-3 (NT-3), a member of the neurotrophin family, has been shown to be necessary for the development of muscle spindle and Merkel cell afferent nerve fibres in animal models. The presence of NT-3 in the suprabasal epidermis, where many unmyelinated sensory fibres terminate, has been shown for the first time. As these fibres are affected in early diabetic neuropathy and a clinical trial of recombinant human NT-3 in diabetic neuropathy is in progress, the concentrations of endogenous NT-3 in skin of 24 patients at different stages of diabetic polyneuropathy have been investigated. NT-3 concentrations, measured with a specific immunoassay, were significantly higher in affected skin biopsies from patients with diabetic neuropathy than matched control skin (diabetic skin 6.32 (1.18) pg/mg v control skin 1.28 (0.05) (mean (SEM)); p<0.004, Mann-Whitney U test), particularly in the later stages. The optical density of NT-3-immunostaining was also significantly greater in the epidermis in diabetic patients (diabetic epidermis 0.30 (0.06) v controls 0.24 (0.01); p<0.02). No correlation was found between individual quantitative sensory tests and the increase of NT-3 concentration. The increase of NT-3 seems to reflect the degree of skin denervation in diabetic neuropathy, and may represent a compensatory mechanism. The concentrations of NT-3 in other peripheral targets deserve study in diabetic neuropathy.

GDNF and its receptor component Ret in injured human nerves and dorsal root ganglia

Glial cell line-derived neurotrophic factor (GDNF) is trophic to motor and sensory neurones in animal models. GDNF mRNA is up-regulated in Schwann cells after peripheral nerve injury in rats. We have quantified and localized GDNF and its receptor component Ret, for the first time in any species, in injured human peripheral nerves and dorsal root ganglia (DRG) avulsed from the spinal cord. Significantly higher levels of GDNF were found in nerve distal to the site of the injury than in proximal or intact nerve, and in avulsed DRG than in post-mortem control DRG. GDNF immunostaining was seen in Schwann cells and in DRG neurones, especially of small and medium size, with significantly increased numbers of medium sized sensory neurones immunoreactive for GDNF after avulsion. Ret immunoreactivity was restricted to DRG neurones and axons, with no significant changes in numbers of positive DRG cells after injury. Our findings suggest that GDNF may play a role in injured human nerves and sensory ganglia, particularly in medium sized sensory neurones.

Nonexpression of CD15 by neoplastic glia: a barrier to metastasis?

Cluster of differentiation 15 (CD15) monoclonal antibodies recognise cell adhesion molecules on the surface of many cells including normal astrocytes and metastatic carcinoma cells. The CD15 epitope (fucosyl-N-acetyl-lactosamine), an adhesive oligosaccharide, functions as a ligand for the selectin family of membrane receptors. These include CD62, a cytokineinducible glycoprotein found in platelets and endothelial cells. CD15 is one of a series of putative adhesion molecules expressed in nervous tissue. Selectin-carbohydrate interactions have been implicated in the metastatic spread of cancer cells. We have immunostained a variety of cultured human brain tumours, three cell lines derived from experimental rat gliomas, two specimens of cultured human foetal astrocytes, two metastatic carcinoma cell lines and human umbilical vein endothelial cells (HUVEC) using two monoclonal antibodies which recognise CD15. While all of the animal glioma cells were positive for CD15, only two human glioma cell lines, derived from an anaplastic astrocytoma and a glioblastoma multiforme, respectively, displayed limited reactivity. Chromium radiolabel binding assays of CD15-positive and -negative cell lines including glioma and carcinoma-derived cells, using HUVEC as an attachment substrate, were carried out in the presence and absence of CD15 monoclonal antibody. The level of adhesion of neoplastic cells to HUVEC not only corresponded to CD 15 expression but application of anti-CD 15 monoclonal antibodies considerably reduced adhesion. We postulate that the absence of CD15 on human glioma cells may explain, to some extent, the general failure of intrinsic brain tumours to metastasis by precluding the adhesion of circulating neoplastic glia to 'target' organ endothelium.

d-Fenfluramine- and d-norfenfluramine-induced hypophagia: differential mechanisms and involvement of postsynaptic 5-HT receptors

Severe depletion of 5-hydroxytryptamine (5-HT) by para-chlorophenylalanine (pCPA, 150 mg/kg per day x3) did not alter the hypophagic effect of d-fenfluramine (1-3 mg/kg i.p.) 1 h after food presentation in 24-h food-deprived rats, and moderately and comparably increased the hypophagic effects of its metabolite, d-norfenfluramine (0.35-1.0 mg/kg i.p.), and of the 5-HT1C receptor agonist, 1-(3-chlorophenyl)piperazine (mCPP; 1.5, 2.0 mg/kg i.p.). Chronic treatment with mCPP (2.5 mg/kg i.p. x 14) attenuated the hypophagia induced by d-norfenfluramine (1, 1.5 mg/kg) but not d-fenfluramine (1, 3 mg/kg). 1-(1-Naphthyl)piperazine (3, 8 mumol/kg s.c.), which has greater affinity for 5-HT1C than for 5-HT2 receptors, had no effect on the hypophagia induced by d-fenfluramine (1.25, 2.0 mg/kg), but 1.3 and 3 mumol/kg 1-(1-naphthyl)piperazine largely and comparably attenuated the substantial hypophagic effect of d-norfenfluramine (0.75 mg/kg). The essentially complete hypophagic action of d-norfenfluramine (1.25 mg/kg) was inhibited by 1-(1-naphthyl)piperazine with ID50 = 2.13 mumol/kg. Ketanserin, which binds more weakly than 1-(1-naphthyl)piperazine to 5-HT1C receptors and more strongly to 5-HT2 receptors, attenuated weaker but not stronger hypophagic effects of d-fenfluramine (1.25, 2.0 mg/kg) when given at high dosage (8, 16 mumol/kg s.c.). Ketanserin (16 mumol/kg) also weakly attenuated the hypophagia due to d-norfenfluramine (0.75 mg/kg), but not the essentially complete hypophagia due to d-norfenfluramine (1.25 mg/kg).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of housing, restraint and chronic treatments with mCPP and sertraline on behavioural responses to mCPP

The effects of pretreatments on behavioural responses to activation of 5-HT1C receptors by m-chlorophenylpiperazine (mCPP) were investigated. The hypo locomotor and anxiogenic effects of mCPP (social interaction test) were influenced neither by previous housing (single versus grouped) nor by restraint (2 h, 24 h previously). In the absence of mCPP, 24 h group housing led to decreased social interaction and the restraint procedure led to significant decreases of feeding and locomotion. The hypophagic effect of mCPP was unaffected by previous restraint. However, chronic pretreatment with mCPP (2.5 mg/kg per day IP x 14) or with the antidepressant 5-HT reuptake inhibitor sertraline (5 mg/kg per day SC x 14) attenuated all three behaviours. The above findings are discussed with respect to published data on effects of pretreatments on responses to the activation of 5-HT1C receptors.

The effect of a peptide aldehyde reversible inhibitor of elastase on a human leucocyte elastase-induced model of emphysema in the hamster

The peptide aldehyde Ro 31-3537, N alpha-(1-adamantanesulphonyl)-N epsilon-(4-carboxybenzoyl)-L-lysyl-L-alanyl-L- valinal, is a reversible competitive, hydrophilic, specific inhibitor of elastase. Its Ki against human leucocyte elastase is 6 x 10(-8) M. The effect of this compound has been studied on a model of emphysema in the hamster induced by multiple sequential intratracheal doses of human leucocyte elastase. Concomitant intratracheal dosing of 200 micrograms of inhibitor with the enzyme significantly reduces lung damage as measured by quasi-static lung compliance and by histological assessment of the emphysema.

A new class of inhibitors of human leucocyte elastase

Studies of the inhibition of elastases at a molecular level have resulted in the identification of protected dipeptides which are reversible and highly specific inhibitors of human leucocyte elastase (HLE). These have been further developed by increasing their hydrophilicity and potency to give a new family of elastase inhibitors, typically N alpha-(1-adamantanesulphonyl)-N epsilon-(4-carboxybenzoyl)-L-lysyl-L-alanyl-L-valinal. These compounds are active in pharmacological models designed to detect compounds of potential therapeutic value in the treatment of emphysema.

Pharmacological and biochemical activities of tenoxicam (Ro 12-0068), a new non-steroidal anti-inflammatory drug

Tenoxicam, a new non-steroidal anti-inflammatory drug has been compared with piroxicam and indomethacin in a range of pharmacological and biochemical inflammation test systems. In a chronic (17-day) adjuvant arthritis in the rat, tenoxicam and piroxicam were equally effective in reducing several indices of inflammation and were less ulcerogenic and better tolerated than indomethacin. The oxicams reduced the oedematous and cellular components of a carrageenan pleurisy at 4 hours while at 24 hours they increased exudate volume and selectively inhibited the accumulation of mononuclear cells. These agents also reduced the inflammatory component of a delayed hypersensitivity response to methylated bovine serum albumin in the mouse. The oxicams were about 100-fold less active than indomethacin as inhibitors of prostaglandin synthetase but all three compounds reduced about equally the release of prostaglandin E2 from phagocytosing rat PMN and interleukin 1-stimulated human rheumatoid synovial cells. The compounds had no effect on the release of superoxide anion, lysosomal enzymes or collagenase from cultured cells, neither did they inhibit isolated collagenase. Only indomethacin stabilized albumin against heat denaturation.

Assessment of drugs for activity in established type II collagen arthritis

Arthritis was induced in a proportion of rats sensitized with type II collagen and Freund's incomplete adjuvant. Rats which developed arthritis had significantly higher antibody titres and significantly greater delayed hypersensitivity responses to type II collagen than rats which did not develop arthritis. Anti-inflammatory and anti-rheumatic drugs were evaluated against type II collagen arthritis. Dexamethasone reduced inflammatory swelling, reduced both the antibody titre and delayed hypersensitivity to type II collagen and exerted joint protection. Indomethacin reduced inflammatory swelling. Azathioprine, Clozic, Levamisole, D-Penicilamine and Sulphapyridine did not exert significant beneficial activity in this test.

An analysis of mineral uptake in apple rootstock seedlings

Eight families from biparental crosses of apple rootstocks and 12 families from open pollinated Malus spp. were analysed in 2 years for N, P, K, Ca and Mg content of the foliage. Highly significant differences were found between the families for all elements. There were no significant differences between the means of the biparental group and the open pollinated group. Ca and K content were significantly more variable in the open pollinated families compared with the biparental families. It is suggested that this increased variation could prove useful in breeding for efficiency of mineral uptake by apple rootstocks.