Community Support for Harm Reduction and Treatment of Opioid Use Disorder

As the opioid epidemic continues, availability of evidence-based strategies for harm reduction and treatment in communities is critical to reduce overdose and other consequences of opioid use disorder. Community members' support of harm reduction and treatment services is needed for new programs and to maintain existent programs. This study sought to understand beliefs and attitudes associated with support for three community-based strategies to address opioid misuse and addiction: naloxone, needle exchange, and medication-assisted treatment. We conducted a cross-sectional online survey with 545 adults. Results of the survey showed that participants supported all three strategies, with the strongest support for medication-assisted treatment. Multiple regression showed that stigma and perceived stigma were significant predictors for all three strategies, with inverse relationships. Stigmatizing beliefs predicted less support while perceiving stigma among others was associated with greater support for the strategies. Normative beliefs also significantly predicted support for all three strategies, such that stronger belief that others were supportive of each strategy was associated with greater support for that strategy. Other predictors varied across the three strategies. Support for harm reduction and treatment programs in communities affected by the opioid epidemic may be bolstered by reducing stigma and increasing normative beliefs. Stronger support for medication-assisted treatment may be leveraged and extended to harm reduction strategies. Results of our study contribute insights for bolstering community support for harm reduction and treatment, which is vital for adoption and maintenance of these important programs.

Role of Trusted Sources and Behavioral Beliefs in Promoting Mitigation Behaviors: Lessons from the COVID-19 Pandemic (Preprint)

Background

Objective

Methods

Results

Conclusions

Seasonal affective disorder and engagement in physical activities among adults in Alaska

Seasonal affective disorder (SAD) is a type of depression in which symptoms occur during a particular season. While physical activity has been shown to improve symptoms for depression in general populations, the relationships between physical activity and experiences of seasonality and SAD remain underexplored. We conducted a survey with adult members of a recreational gym in Fairbanks, Alaska. The survey collected self-report data on sociodemographics, health behaviours, and elements of the Seasonal Pattern Assessment Questionnaire (SPAQ). Results indicate that 18.68% of our study participants meet the criteria for winter-pattern SAD and 43.96% meet the criteria for subsyndromal SAD ("winter blues"). We conducted two regressions to understand experiences of SAD and predictors of seasonality more generally. Gender was a significant predictor of SAD, with women more likely than men to experience SAD (p = .04). Being social at the gym, whether going to the gym with others or participating in activities with others, was associated with higher seasonality than being independent at the gym (p = .03). Younger age was also associated with higher seasonality (p < .001). This study contributes new insights about the relationship between engagement in physical activities and experiences of seasonality among adults in a northern latitude.

Preventing opioid overdose with peer-administered naloxone: findings from a rural state

BACKGROUND

In response to the opioid epidemic, naloxone distribution programs aim to prevent overdose death by making naloxone available and training people to use it. Peers of individuals at risk of opioid overdose are well-positioned to administer naloxone and prevent overdose death.

METHODS

We conducted key informant interviews with 18 individuals with past or current opioid and heroin drug use who had administered naloxone to a peer during an overdose emergency. Interviews explored individuals' experiences with administration and their recommendations for program and policy improvement. Data were systematically coded and analyzed for themes.

RESULTS

Participants sought naloxone rescue kits because they perceived high risk of overdose. They described high satisfaction with training and felt prepared to administer naloxone during overdose incidents. Overwhelmingly, participants perceived naloxone to be effective and emphasized the need to make it widely available. Findings suggest that engagement in overdose prevention strategies other than naloxone differs by gender, with females more likely than males to use multiple different strategies. Participants described that overdose experiences do not have a lasting impact on drug use behaviors.

CONCLUSIONS

Findings support the feasibility of naloxone distribution to peer opioid and heroin users and provide recommendations for policy improvement, including effective and well-advertised Good Samaritan laws and links to treatment for opioid use disorder.

Examining the sustainability potential of a multisite pilot to integrate alcohol screening and brief intervention within three primary care systems

The U.S. Preventive Services Task Force recommends that clinicians adopt universal alcohol screening and brief intervention as a routine preventive service for adults, and efforts are underway to support its widespread dissemination. The likelihood that healthcare systems will sustain this change, once implemented, is under-reported in the literature. This article identifies factors that were important to postimplementation sustainability of an evidence-based practice change to address alcohol misuse that was piloted within three diverse primary care organizations. The Centers for Disease Control and Prevention funded three academic teams to pilot and evaluate implementation of alcohol screening and brief intervention within multiclinic healthcare systems in their respective regions. Following the completion of the pilots, teams used the Program Sustainability Assessment Tool to retrospectively describe and compare differences across eight sustainability domains, identify strengths and potential threats to sustainability, and make recommendations for improvement. Health systems varied across all domains, with greatest differences noted for Program Evaluation, Strategic Planning, and Funding Stability. Lack of funding to sustain practice change, or data monitoring to promote fit and fidelity, was an indication of diminished Organizational Capacity in systems that discontinued the service after the pilot. Early assessment of sustainability factors may identify potential threats that could be addressed prior to, or during implementation to enhance Organizational Capacity. Although this study provides a retrospective assessment conducted by external academic teams, it identifies factors that may be relevant for translating evidence-based behavioral interventions in a way that assures that they are sustained within healthcare systems.

The Relationship Between Mixed Race/Ethnicity, Developmental Assets, and Mental Health Among Youth

This study assessed whether high school youth with mixed race/ethnicity are at greater risk for poor mental health conditions compared to their single race/ethnic counterparts and whether this mental health risk can be mitigated by youth developmental assets regardless of one's race/ethnicity. Methods involved secondary data analysis of the 2009-2013 Youth Risk Behavioral Survey-Anchorage, Alaska subsample. Difference in rates of mental health conditions and mean number of developmental assets (protective factors) were assessed among three racial/ethnic groups. Logistic regression models tested whether race/ethnicity has an independent association with mental health conditions and whether there is an interaction effect between race/ethnicity and protective factors. Results show that, compared to white students, mixed race/ethnic students have significantly higher rates of poor mental health condition and significantly fewer protective factors. A significant interaction effect between race/ethnicity and protective factors was also found, showing decreasing likelihood of poor mental health condition with increasing number of protective factors among all racial/ethnic groups. However, this effect was more pronounced among white students compared to both mixed and single race/ethnicity minority students. Study findings indicate that youth of mixed race/ethnicity are more likely to be at risk for poor mental health outcomes, yet less likely to mitigate this risk even with similar number of external developmental assets as their single race/ethnic counterparts. More research is needed to further understand the differential effect of certain developmental assets among different racial/ethnic groups.

An Environmental Scan of the Role of Nurses in Preventing Fetal Alcohol Spectrum Disorders

Nurses are in an ideal position to talk to their patients of reproductive age about alcohol use and encourage the prevention of alcohol-exposed pregnancies. Effective conversations can be efficiently included in the clinical encounter to identify alcohol misuse and offer appropriate follow-up. This report presents results of an environmental scan of resources relevant to nursing professionals and nurses' role in addressing alcohol misuse. Gaps in nursing education and practice guidelines with regard to defining the nursing role in preventing alcohol-exposed pregnancies were revealed. Findings identified a need to promote adoption among nurses of evidence-based preventive practices to prevent alcohol misuse.

Key Stakeholders' Perceptions of Motivators for Research Participation Among Individuals Who Are Incarcerated

Understanding motivations of research participants is crucial for developing ethical research protocols, especially for research with vulnerable populations. Through interviews with 92 institutional review board members, prison administrators, research ethicists, and researchers, we explored key stakeholders' perceptions of what motivates incarcerated individuals to participate in research. Primary motivators identified were a desire to contribute to society, gaining knowledge and health care, acquiring incentives, and obtaining social support. The potential for undue influence or coercion were also identified as motivators. These results highlight the need for careful analysis of what motivates incarcerated individuals to participate in research as part of developing or reviewing ethically permissible and responsible research protocols. Future research should expand this line of inquiry to directly include perspectives of incarcerated individuals.

Perceived control as a longitudinal moderator of late-life stressors on depressive symptoms

OBJECTIVES

This study examined perceived control as a moderator of the relationship between late-life stressors and depressive symptoms among a sample of older New Zealanders.

METHOD

Data were drawn from a longitudinal study with two data collection periods, one year apart. The Time 1 sample consisted of 1489 participants ranging in age from 65 to 94 years and 72% percent participated at Time 2. Correlational and multiple regression procedures were used to examine study hypotheses.

RESULTS

Results showed that Time 1 perceived control beliefs were a unique predictor of depressive symptoms at Time 2 after controlling for Time 1 depressives symptoms and other relevant variables. Further, perceived control beliefs at Time 1 moderated the relationship between late-life stressors and depressive symptoms at Time 2. Those with low perceived control demonstrated a stronger relationship between late-life stressors and depressive symptoms than those with high perceived control.

CONCLUSION

This study provides evidence that perceived control influences levels of depressive symptoms over time among older adults. Results also support the hypothesis that control beliefs moderate the relationship between late-life stressors and depressive symptoms among older adults. Implications include attributional retraining to promote perceived control and subsequent well-being in older adults.

Conducting Ethical Research with Correctional Populations: Do Researchers and IRB Members Know the Federal Regulations?

Conducting or overseeing research in correctional settings requires knowledge of specific federal rules and regulations designed to protect the rights of individuals in incarceration. To investigate the extent to which relevant groups possess this knowledge, using a 10-item questionnaire, we surveyed 885 IRB prisoner representatives, IRB members and chairs with and without experience reviewing HIV/AIDS correctional protocols, and researchers with and without correctional HIV/AIDS research experience. Across all groups, respondents answered 4.5 of the items correctly. Individuals who have overseen or conducted correctional research had the highest scores; however, even these groups responded correctly only to slightly more than half of the items. These findings emphasize the need for ongoing training in federal guidelines governing correctional research, particularly for those individuals who are embarking on this type of research.

Later life health optimism, pessimism and realism: psychosocial contributors and health correlates

Prior research has established positive outcomes of health optimism (appraising one's health as good despite poor objective health (OH)) and negative outcomes of health pessimism (appraising health as poor despite good OH), yet little is known about their contributors. We examined the role of psychosocial factors (life event stress, depression, dispositional optimism, perceived social support) in health realism (appraising health in accordance with OH), optimism and pessimism among 489 older men and women. We then accounted for the psychosocial factors when examining multiple health correlates of health realism, optimism and pessimism. Controlling for age, gender and income, regression results indicate that depression and social support were associated with less health optimism, while dispositional optimism was associated with greater health optimism among those in poor OH. Dispositional optimism was associated with less health pessimism and life event stress was associated with greater pessimism among those in good OH. Beyond the effects of the psychosocial factors, structural equation model results indicate that health optimism was positively associated with healthy behaviours and perceived control over one's health; health pessimism was associated with poorer perceived health care management. Health optimism and pessimism have different psychosocial contributors and health correlates, validating the health congruence approach to later life well-being, health and survival.

The Unique Role of Sleep Quality in Older Adults’ Psychological Well-Being

Previous research has established a link between sleep quality and psychological well-being in older adults. However, no research to date has investigated this relationship in the context of other factors known to influence both sleep and psychological well-being. Among a sample of 489 independently living older adults (ages 60 to 98), the current study examined the association between sleep quality and psychological well-being (positive emotions, negative emotions, depression) while controlling for individual differences in factors known to affect sleep: physical health, stress, physical activity, functional ability, and demographics. Multiple linear regression models showed that both better current sleep quality and better comparative sleep quality (from middle to older adulthood) predicted better psychological well-being. Implications include interventions to improve sleep quality in older adults.

Perceived barriers to health care and health behaviours: implications for Native American elders' self-rated health

Little is known about how Native American adults appraise their health in later life. Perceived barriers to health care and health behaviours were examined among 6813 Native elders to determine their unique associations with self-rated health (SRH). Hierarchical regression results showed inability to access needed medical care predicted poorer SRH. Statistically accounting for sociodemographics and barriers to care, health behaviours predicted SRH. The current findings suggest opportunities to improve Native elders' SRH particularly via exercise and good nutrition. In turn, enhanced SRH may lead to improved quality of life.

Endoscopic management of tumors of the major duodenal papilla: Refined techniques to improve outcome and avoid complications

BACKGROUND

Adenomas of the major duodenal papilla have malignant potential and are traditionally treated by pancreaticoduodenectomy. This is a report of our experience with endoscopic management and a description of techniques for decreasing complications and enhancing efficacy.

METHODS

Forty-one patients were referred for endoscopic management of papillary tumors. If there was no duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy with pancreatic duct stent placement was performed. If the lesion could be elevated by injection of an epinephrine solution, piecemeal resection was performed. The base of the lesion was thermally ablated as needed. Resection/ablation together with stent removal was performed 1 month later.

RESULTS

Nine patients (22%) had lesions other than papillary adenoma or cancer. Malignant appearance, ductal stricturing, or extension into the ducts was found in 16 of 41 patients (39%) in whom biopsy specimens alone were obtained. Three patients with adenomas (7%) did not undergo endoscopic resection (because of extremely large lesions and/or comorbid illnesses). Thirteen patients with adenomas (32%) had endoscopic resection; 12 (92%) were lesion-free after 32 ERCPs (mean 2.7). Endoscopic management was unsuccessful in 1 patient (8%). Pancreatitis developed in 1 patient.

CONCLUSIONS

Endoscopically treatable papillary neoplasms can be identified on the basis of endoscopic, radiographic, and biopsy features. Preresection sphincterotomy, stent placement, elevation by epinephrine injection, and piecemeal resection may reduce complications and permit more aggressive treatment.

Methylation of histone H3 by coactivator-associated arginine methyltransferase 1

The preferential in vitro methylation of histone H3 by coactivator-associated arginine methyltransferase 1 (CARM1) has been proposed as a basis for its ability to enhance gene transcription [Chen, D., et al. (1999) Science 284, 2174-2177]. To further evaluate the significance of H3 methylation, we studied the kinetics and site specificity of its modification by CARM1. Affinity-purified CARM1 methylated recombinant chick H3, which is free of posttranslational modifications, and calf thymus H3, which is heterogeneous with regard to preexisting modifications, equally well, exhibiting a V(max) of 4500 pmol min(-1) (mg of enzyme)(-1) and an apparent K(m) for H3 of < or = 0.2 microM. The catalytic efficiency (k(cat)/K(m)) of CARM1 toward H3 was at least 1000 times that toward R1 (GGFGGRGGFGG-amide), a highly effective substrate for protein arginine methyltransferase 1. Peptide mapping of 3H-methyl-labeled H3 indicated methylation at Arg-2, Arg-17, and Arg-26 in the N-terminal region and at one or more of four arginines (128/129/131/134) at the C-terminus. Two of the N-terminal sites, Arg-17 and Arg-26, occur in the sequence KAXRK and appear to be more efficiently methylated than Arg-2. CARM1 catalyzed formation of N(G),N(G)-dimethylarginine (asymmetric) but little or no N(G),N'(G)-dimethylarginine (symmetric) and no form of methyllysine. Amino acid analysis of untreated calf thymus H3 revealed that 3.7% of the molecules naturally contain asymmetric dimethylarginine and/or monomethylarginine. Our findings support the hypothesis that methylation of H3 may be involved in the mechanism of transcriptional coactivation by CARM1 of genes whose expression is under the control of nuclear receptors.

Asymmetries in the nucleosome core particle at 2.5 A resolution

The 2.5 A X-ray crystal structure of the nucleosome core particle presented here provides significant additions to the understanding of the nucleosome, the fundamental unit of chromatin structure. Extensions are made to the structure of the N-terminal histone tails and details are provided on hydration and ion binding. The structure is composed of twofold symmetric molecules, native chicken histone octamer cores and the DNA palindrome, which were expected to form a perfectly twofold symmetric nucleosome core particle. In fact, the result is asymmetric owing to the binding of the DNA to the protein surface and to the packing of the particles in the crystal lattice. An analysis is made of the asymmetries by comparisons both within the nucleosome core particle and to the structure of the histone octamer core of the nucleosome.

Infected pancreatic pseudocysts with colonic fistula formation successfully managed by endoscopic drainage alone: report of two cases

Fistulization of pancreatic pseudocysts into surrounding viscera is a well-known phenomenon and usually requires surgical management. We report two cases of pancreatic pseudocysts that developed spontaneous fistulas to the colon with resulting fever and abdominal pain. The patients were managed nonoperatively with a combination of endoscopic drainage and antibiotics, and their pseudocysts and fistulas resolved. The patients have remained symptom-free for a mean of 14 months of follow-up.

Endoscopic treatment of pancreatic duct stones using a 10F pancreatoscope and electrohydraulic lithotripsy

BACKGROUND

Endoscopic therapy with adjunctive extracorporeal shock wave lithotripsy fails to provide clearance of pancreatic duct stones in up to 25% of symptomatic patients. Direct contact lithotripsy may provide an additional option for removal of refractory stones. We report our initial experience using a prototype 10F "baby" endoscope to administer electrohydraulic lithotripsy.

METHODS

Five patients failing extracorporeal shock wave lithotripsy and one patient with recurrent pancreatic duct stones after surgery were selected to undergo endoscopic electrohydraulic lithotripsy. After pancreatic sphincterotomy and balloon dilation (8 or 10 mm), the 10F endoscope was introduced and electrohydraulic lithotripsy was used to fragment stones under direct visualization.

RESULTS

Six patients underwent 9 intraductal electrohydraulic lithotripsy procedures. Complete or partial pancreatic duct clearance was accomplished in all but one. No complications from the lithotripsy procedure were noted. The 5 patients with partial or complete duct clearance experienced complete relief of abdominal pain of at least 6 months' duration following their final procedure.

CONCLUSION

Electrohydraulic lithotripsy within the pancreatic duct provides an adjunctive endoscopic option for treatment of patients with symptomatic pancreatic duct stones. Our initial experience suggests that electrohydraulic lithotripsy therapy can successfully fragment stones refractory to conventional endoscopic stone extraction methods or extracorporeal shock wave lithotripsy. Further experience is necessary to establish the risks of electrohydraulic lithotripsy within the pancreatic duct.

Macromolecular crystal annealing: evaluation of techniques and variables

Additional examples of successful application of macromolecular crystal annealing are presented. A qualitative evaluation of variables related to the annealing process was conducted using a variety of macromolecular crystals to determine in which cases parameters may be varied and in which cases the original macromolecular crystal annealing protocol is preferred. A hypothesis is presented relating the solvent content of the crystal to the specific protocol necessary for the successful application of annealing.

Dilated common channel syndrome: endoscopic diagnosis, treatment, and relationship to choledochocele formation

BACKGROUND

Choledochoceles (type III biliary cysts) are cystic dilations of the terminal common bile duct or common pancreatobiliary channel. Although no size criteria have been defined, it is generally assumed these must be large. However, we describe patients who do not meet the perceived size criteria for choledochoceles, but who nonetheless have a dilated common pancreatobiliary channel.

METHODS

We reviewed the presenting symptoms, endoscopic and radiographic findings, and response to endoscopic therapy of patients meeting our criteria for the dilated common channel syndrome.

RESULTS

Of 2847 patients undergoing ERCP, 100 (3.5%) had the dilated common channel syndrome. Common presenting symptoms and signs included abdominal pain in 97%, abnormal liver function test(s) in 66%, and a history of acute or recurrent pancreatitis in 46%. A bulge was visible above the papilla in 88%, with a dilated common bile duct in 54% and a dilated pancreatic duct in 28%. After endoscopic unroofing of the common channel, 77% had complete and long-lasting resolution of symptoms, 18% had partial or transient improvement, and 5% had no change.

CONCLUSIONS

Although classic choledochoceles are rare, a lesser degree of dilation of the common channel is more frequent than generally appreciated. We postulate that this finding represents an "incomplete," acquired form of choledochocele, possibly caused by underlying papillary stenosis. Whatever the etiology and appropriate term, the presence of a dilated common channel predicts a high rate of clinical response to endoscopic therapy.

Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique

BACKGROUND

Endoscopic pancreatic sphincterotomy is less widely practiced than biliary sphincterotomy, in part because of the lack of firm data regarding its indications and safety. In addition, recent reports of ductal and parenchymal changes occurring after pancreatic stenting raise concerns about the standard practice of stent placement at the time of pancreatic sphincterotomy. We report our experience with pancreatic sphincterotomy and describe the use of a technique involving overnight nasopancreatic drainage rather than stenting.

METHODS

We reviewed the records of the 164 pancreatic sphincterotomies performed on 160 patients at our institution between January 1, 1991, and October 1, 1996, comparing procedures done with overnight nasopancreatic catheter placement with those done with stenting or no drainage. We also examined the long-term clinical outcome of patients after pancreatic sphincterotomy.

RESULTS

Of the 164 sphincterotomies, 98 were done with overnight nasopancreatic drainage, 50 with stent placement, and 16 with no drainage. Complications (all pancreatitis) were significantly more frequent in the group with no drainage (12.5%) as compared with those with drainage (0.7%); p < 0.003. Nasopancreatic drainage was as safe as stent placement, with no complications after 98 procedures. Pancreatic sphincterotomy was effective when used as primary therapy, with 64% of patients so treated experiencing complete and long-lasting resolution of symptoms after the procedure.

CONCLUSIONS

Pancreatic sphincterotomy is safe and effective, although pancreatic drainage is required to reduce the incidence of pancreatitis. Overnight nasopancreatic drainage is the method of choice, as it carries as low a complication rate as stent placement, but without the need for a repeat procedure, and presumably without the risk of ductal and parenchymal damage.

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts

OBJECTIVE

To provide current information on the risks of endoscopic sphincterotomy for stone.

SUMMARY BACKGROUND DATA

In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients.

METHODS

Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria.

RESULTS

Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm.

CONCLUSION

Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Crystallographic Analysis of Antigen-Antibody Complexes: End-on Insertion of Ligands in Antibodies-CDR3 Loops as Arbiters

As the dominant constituents of the active sites, complementarity-determining regions (CDRs) and particularly the CDR3 loops strongly influence the size and shape of this interdomain space. Six sets of CDR3 loops were extracted from our collection of crystal structures and examined for their modes of association. The CDR3 loops of the NC6.8 Fab face each other across a small crevice that is expanded further by end-on insertion of its high-affinity ligand (a trisubstituted guanidine sweet-tasting compound). This wedging event triggers a series of extensive local and transmitted conformational changes. In the 4-4-20 Fab, the CDR3 loops provide scaffolding for the high-affinity binding of fluorescein and shield the ligand from bulk solvent in the interdomain space above and below the very compact binding slot. Constituents of the CDR2 and CDR3 loops of the BV04-01 Fab interact to form "false floors" over potential cavity-type sites and thereby eliminate end-on insertion. Instead, fragments of single-stranded DNA are bound with low affinity in a groove whose course is altered on complex formation by global movements of VH relative to VL and by local shifts of HCDR3. Trafficking of even small peptide ligands between the V domains of the Pot Fv is prevented by the collapse of the large HCDR3 segment into the residual interdomain space. This protein is better suited to polyreactive binding of a variety of large protein antigens on its external surfaces. By comparison, the space available between the CDR3 loops of the Mcg light-chain dimer is very large. It has proved to be accessible for end-on insertion of peptides and other ligands ranging over seven orders of magnitude in affinity. Recently, an insect neuropeptide hormone, with pGlu as its penetrating agent, has been found to pierce the entire V dimer interface from the entrance of the traditional active site to the solvent pool between the V and C domains. In an Mcg x Hud heterodimer, the Hud CDR3 plays a role similar to that of the Pot H chain and blocks access to the interdomain space by close interactions with the CDR3 of Mcg.

Combined modality treatment of symptomatic pancreatic ductal lithiasis

OBJECTIVE

To assess the efficacy and safety of the removal of pancreatic duct stones by a combined modality approach in patients with pancreatic ductal lithiasis and recurrent abdominal pain.

DESIGN

Retrospective review with a mean follow-up of 19 months (range, 1 to 56 months).

SETTING

A tertiary care, private community hospital with a university affiliation.

PATIENTS

The records of patients who presented to the hospital or who were referred with recurrent abdominal pain and who were demonstrated to have pancreatic ductal lithiasis between 1989 and 1994 were reviewed. Patients were assessed by their clinical response to pancreatic duct stone extraction by a variety of therapeutic interventions.

RESULTS

Fifteen patients were included in the study. One patient was excluded from analysis because of a concurrent choledochocele. Two patients required operative decompression and stone extraction for endoscopically inaccessible stones. Six patients were treated with endoscopic management alone, and six were treated with a combination of extracorporeal shock wave lithotripsy and endoscopic stone retrieval. Twelve patients had complete clearance of the pancreatic duct. One patient had a stone that was not removed, but adequate pancreatic ductal decompression was achieved. The remaining patient had incomplete clearance of pancreatic stone fragments following extracorporeal shock wave lithotripsy but had adequate ductal drainage. No patient has required further therapy or hospitalization for abdominal pain. No complications occurred as a result of any intervention in this study.

CONCLUSIONS

A multidisciplinary combined modality approach is a safe and effective method for extracting pancreatic duct stones in symptomatic patients. Stone extraction and reestablishment of adequate ductal drainage appear to relieve symptoms in some patients.

Utility of endoscopic retrograde cholangiopancreatography in the evaluation of idiopathic abdominal pain

We investigated the role of endoscopic retrograde cholangiopancreatography in 86 consecutive patients with idiopathic chronic or recurrent abdominal pain. There were 18 males and 68 females with a mean age of 48 yr. Forty patients (47%) had previous cholecystectomy. Patients were divided into two groups: group I (normal serum alkaline phosphatase and total bilirubin) (n = 52), and group II (elevated serum alkaline phosphatase and/or total bilirubin) (n = 34). Pancreatograms were normal in all patients, including five with pancreas divisum. Cholangiograms were abnormal in 10 of the 34 patients in group II (30%), and in only three of the 52 patients in group I (6%) (p = 0.003). Bile duct stones were present in 18% of the patients in group II, and in none of the patients in group I (p = 0.003). Of the 40 post-cholecystectomy patients, four patients had bile duct stones and five had common bile duct dilation without stones. However, no stones were found in any post-cholecystectomy patients with normal liver tests. Of the 46 patients with gallbladder in situ, two patients with abnormal liver tests had common bile duct stones and two patients had common bile duct dilation without stones. These results indicate that, among patients with idiopathic abdominal pain, cholangiography should be performed primarily in those with abnormal liver tests; however, further investigation with pancreatography is unnecessary.

Principles and pitfalls in designing site-directed peptide ligands

An immunoglobulin light chain dimer with a large generic binding cavity was used as a host molecule for designing a series of peptide guest ligands. In a screening procedure peptides coupled to solid supports were systematically tested for binding activity by enzyme linked immunosorbent assays (ELISA). Key members of the binding series were synthesized in milligram quantities and diffused into crystals of the host molecule for X-ray analyses. These peptides were incrementally increased in size and affinity until they nearly filled the cavity. Progressive changes in binding patterns were mapped by comparisons of crystallographically refined structures of 14 peptide-protein complexes at 2.7 A resolution. These comparisons led to guidelines for ligand design and also suggested ways to modify previously established binding patterns. By manipulating equilibria involving histidine, for example, it was possible to abolish one important intramolecular interaction of the bound ligand and substitute another. These events triggered a change in conformation of the ligand from a compact to an extended form and a comprehensive change in the mode of binding to the protein. In dipeptides of histidine and proline, protonation of both imidazolium nitrogen atoms was used to program an end-to-end reversal of the direction in which the ligand was inserted into the binding cavity. Peptides cocrystallized with proteins produced complexes somewhat different in structure from those in which ligands were diffused into preexisting crystals. In such a large and malleable cavity, space utilization was thus different when a ligand was introduced before the imposition of crystal packing restraints.

Bicultural training for new graduates

This article demonstrates the success of a bicultural training program in helping new graduates successfully integrate the transition from student to staff nurse. It describes how to implement this program and how to train 'trainers' for it. Results based on turnover rates and cost-effectiveness verify its usefulness.

A statistical model for length of stay in a mental hospital

The log-normal distribution is presented as a model for the probability distribution of length of hospitalization of mental patients. In general, the log-normal parameters differ for various diagnoses and treatment institutions. Data from several samples of patients are offered as evidence in support of the log-normal function. The implications of this function, such as the multiplicative effects of the factors involved in length of stay, are discussed.