The problem of over-medicalisation: How AOD disease models perpetuate inequity for young people with multiple disadvantage

Young people who experience multiple disadvantage have been identified as some of the most marginalised and under-serviced people in the alcohol and other drug (AOD) system. In this paper, we draw on a range of research evidence to argue that one of the challenges in responding appropriately to the needs of these young people are models of care which seek to ameliorate 'illness' rather than promote wellness. While disease approaches have some important benefits, overly-medicalised AOD treatment responses also have negative impacts. We argue that disease models rest on understandings of substance use as an individual enterprise and thereby pay insufficient attention to the material disadvantage that shape young people's substance use, creating feelings of shame, failure and a reluctance to return to care if they continue to use. Additionally we draw on literature that shows how disease models construe young people's substance use as compulsive, perpetuating deficit views of them as irrational and failing to account for the specific meanings that young people themselves give to their substance use. By focusing on clinical solutions rather than material and relational ones, medicalised treatment responses perpetuate inequity: they benefit young people whose resources and normative values align with the treatments offered by disease models, but are much less helpful to those who are under-resourced,. We suggest that alternative approaches can be found in First Nations models of care and youth programs that attend to social, cultural, and material wellbeing, making living well the focus of treatment rather than illness amelioration.

Community pharmacists' views on providing a reproductive health service to women receiving opioid substitution treatment: A qualitative study using the TDF and COM-B

Background

The absence of menstruation is common in women who use drugs. This can give a belief that conception is unlikely. When stabilised on Opioid Substitution Treatment (OST), fertility often returns, initially without realisation as ovulation precedes menstruation. This leaves women vulnerable to unplanned pregnancies. Community pharmacists (CPs) are frequently in contact with this patient group through the Supervised Consumption of OST service. This provides a timely opportunity to provide reproductive health (RH) advice. The aim of this study was to investigate pharmacists' views on providing a RH service to women receiving OST.

Methods

Twenty semi-structured interviews based on the Capability-Opportunity-Motivation to Behaviour (COM-B) model and the Theoretical Domains Framework (TDF) were conducted between 2016 and 2017. Data analysis involved deductive coding using the TDF domains. The TDF domains were mapped onto the elements of the COM-B and used in the second step to create the framework and chart the data. The third step involved re-reading and clustering the codes, and inductive themes were generated to explain the data in depth.

Results

Nine of the 14 TDF domains, mapped into five elements of the COM-B, were identified. Five inductive themes were generated: 1) The pharmacists' experience and knowledge of reproductive health (RH) needs of women receiving OST, 2) The pharmacists' approach to providing advice, 3) The pharmacists' perception of the relationship with women receiving OST, 4) Social influences, and 5) Environmental factors. Community pharmacists feared causing offense to women receiving OST and described requiring cues as to when the service was needed. Pharmacists' highlighted a power imbalance in the relationship with women receiving OST. This could influence how receptive this patient group would be to pharmacy RH interventions.

Conclusions

CPs' concerns of providing RH service could hinder a proactive service provision. Supporting good rapport and providing a structured consultation would increase the accessibility of such a service.

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Reproductive health advice is triggered by social or physical cues from women.

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Provision of this advice is subject to the reflective thinking of the provider.

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A power imbalance characterizes supervised opioid substitution treatment.

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Good rapport and a structured consultation were seen to increase the accessibility.

Physical activity and the prevention, reduction, and treatment of alcohol and other drug use across the lifespan (The PHASE review): A systematic review

The aim of this review is to systematically describe and quantify the effects of PA interventions on alcohol and other drug use outcomes, and to identify any apparent effect of PA dose and type, possible mechanisms of effect, and any other aspect of intervention delivery (e.g. key behaviour change processes), within a framework to inform the design and evaluation of future interventions. Systematic searches were designed to identify published and grey literature on the role of PA for reducing the risk of progression to alcohol and other drug use (PREVENTION), supporting individuals to reduce alcohol and other drug use for harm reduction (REDUCTION), and promote abstinence and relapse prevention during and after treatment of alcohol and other drug use (TREATMENT). Searches identified 49,518 records, with 49,342 excluded on title and abstract. We screened 176 full text articles from which we included 32 studies in 32 papers with quantitative results of relevance to this review. Meta-analysis of two studies showed a significant effect of PA on prevention of alcohol initiation (risk ratio [RR]: 0.72, 95%CI: 0.61 to 0.85). Meta-analysis of four studies showed no clear evidence for an effect of PA on alcohol consumption (Standardised Mean Difference [SMD]: 0.19, 95%, Confidence Interval -0.57 to 0.18). We were unable to quantitatively examine the effects of PA interventions on other drug use alone, or in combination with alcohol use, for prevention, reduction or treatment. Among the 19 treatment studies with an alcohol and other drug use outcome, there was a trend for promising short-term effect but with limited information about intervention fidelity and exercise dose, there was a moderate to high risk of bias. We identified no studies reporting the cost-effectiveness of interventions. More rigorous and well-designed research is needed. Our novel approach to the review provides a clearer guide to achieve this in future research questions addressed to inform policy and practice for different populations and settings.

FRI0235 PHASE 1 CLINICAL STUDY OF MGTA-145 IN COMBINATION WITH PLERIXAFOR SHOWS RAPID SINGLE-DAY MOBILISATION AND COLLECTION OF CD34+ HAEMATOPOIETIC STEM CELLS WITHOUT G-CSF

Background:

Autologous haematopoietic stem cell (HSC) transplantation is a recommended therapeutic option for selected patients with autoimmune diseases. G-CSF mobilisation of HSCs requires 4-7 days of injections that are associated with significant side effects and potential for severe complications including disease flares (e.g., scleroderma and multiple sclerosis). MGTA-145 is a biologic that activates CXCR2 on neutrophils, and with plerixafor rapidly mobilises HSCs in mice and non-human primates. The combination promises to be a same-day, G-CSF-free mobilisation regimen.

Objectives:

To evaluate the safety, tolerability, and mobilisation efficacy of MGTA-145 monotherapy and combination therapy with plerixafor in healthy volunteers.

Methods:

This healthy volunteer phase 1 study consisted of 4 parts- Part A: single-agent MGTA-145 or placebo; Part B: MGTA-145 or placebo given immediately or 2 hours after plerixafor; Part C: MGTA-145 or placebo given 2 hours after plerixafor on 2 consecutive days; Part D: MGTA-145 given 2 hours after plerixafor, just prior to apheresis cell collection.

Results:

Monotherapy of MGTA-145 mobilised CD34+ cells within minutes and peaked within 1 hour post MGTA-145 (median 11 CD34+ cells/µL, a 7-fold increase vs baseline). White blood cells and neutrophils followed a similar pattern. Importantly, markers of neutrophil activation were relatively unchanged (≤2-fold vs baseline).

MGTA-145 combined with plerixafor increased CD34+ cell mobilisation, whether given simultaneously or 2h after plerixafor (Fig. 1A). Mobilisation was highly enriched for CD34+CD90+CD45RA- HSCs, which tracked closely with the total CD34 count. At the 0.03 mg/kg dose with 2h stagger, median peak CD34+ peripheral blood mobilisation was ≥40 cells/µL in Part B. On a second consecutive day of dosing, MGTA-145 + plerixafor mobilises HSCs to levels comparable to day 1. Initial data from the ongoing Part D show that sufficient numbers of cells (median 4.3 x 10^6 CD34+ cells/kg) for transplant were collected in a single day.. Preliminary data from NSG mouse transplant studies of those mobilised HSCs in part D show higher engraftment rates of MGTA-145 + plerixafor mobilised HSCs, compared to G-CSF-mobilised HSCs.

Figure.

Peripheral blood mobilisation after plerixafor + 0.03 mg/kg MGTA-145 in healthy subjects with simultaneous and 2h stagger dosing after plerixafor. Dotted line: previously reported CD34+ counts with plerixafor alone mobilisation (Chenet al,Blood Advances. 2018).

MGTA-145 monotherapy was well tolerated with no significant adverse events (AEs). Grade 1, transient lower back pain that dissipated within minutes was reported. The combination of MGTA-145 with plerixafor was well tolerated, with some subjects experiencing grade 1/2 gastrointestinal AEs commonly observed with plerixafor and one grade 2 back pain with MGTA-145 at 0.075 mg/kg that resolved within minutes.

Conclusion:

MGTA-145 monotherapy was well-tolerated and induced rapid mobilisation of significant numbers of HSCs. CD34+ cell mobilisation with MGTA-145 + plerixafor was immediate and superior to plerixafor alone. These data suggest that the combination can enable the collection of sufficient HSCs for transplant in one day without the need for G-CSF. Further development as a first line mobilisation product is warranted in autoimmune diseases, gene therapy and haematologic malignancies.

Table.

Single-day Mobilisation and Apheresis Cell Yields in Part D

SubjectTotal CD34+ Yield (x106 cells)CD34+/kg (x106 cells)CD90+ (%)8013194.139%8073224.441%8175005.326%821 (*completed only 13L of planned 20L collection)2392.719%Median3214.333%

Disclosure of Interests:

John Dipersio Shareholder of: Magenta, Consultant of: Cellworks, Tioma, Rivervest, Bioline, Asterias, Amphivena and Bluebird, Celgene, Incyte, NeoImuneTech, Macrogenics, Steven Devine: None declared, Jonathan Hoggatt Shareholder of: Magenta, Grant/research support from: Magenta, Consultant of: Magenta, David Scadden Shareholder of: Magenta, Consultant of: Magenta, Haley Howell Shareholder of: Magenta, Employee of: Magenta, Veit Schmelmer Shareholder of: Magenta, Employee of: Magenta, Jason Neale Shareholder of: Magenta, Employee of: Magenta, Tony Boitano Shareholder of: Magenta, Employee of: Magenta, Michael Cooke Shareholder of: Magenta, Employee of: Magenta, Dwight Morrow Shareholder of: Magenta, Employee of: Magenta, Glen Raffel Shareholder of: Magenta, Employee of: Magenta, Will Savage Shareholder of: Magenta, Employee of: Magenta, Kevin Goncalves Shareholder of: Magenta, Employee of: Magenta, Pat Falahee Shareholder of: Magenta, Employee of: Magenta, John Davis Shareholder of: Magenta, Employee of: Magenta

Colposcopy information leaflets: what women want to know and when they want to receive this information

OBJECTIVES

To evaluate whether the information leaflets produced by UK colposcopy clinics provide women with the information they desire and to determine when they would like to receive this information.

DESIGN

Questionnaire study and structured evaluation.

SETTING

The colposcopy clinic of a UK cancer centre.

PARTICIPANTS

Forty-two women attending a pre-colposcopy counselling session and 100 consecutive women attending the colposcopy clinic.

METHODS

Thirty-eight standards derived from the concerns/questions asked by women attending a pre-colposcopy counselling session were used to assess locally produced colposcopy clinic leaflets from UK colposcopy clinics, the leaflets produced by the Royal College of Obstetricians and Gynaecologists and the National Health Service Cervical Screening Programme (NHSCSP), and two "leaflets" obtained from internet sites. The Gunning fog test was used to assess the leaflets' readability. A questionnaire survey of 100 women attending the colposcopy clinic was used to determine when women wanted to receive information about colposcopy.

MAIN OUTCOME MEASURES

Percentage of questions answered by a given leaflet and Gunning fog scores for readability.

RESULTS

The information leaflets of 128 colposcopy clinics were received and assessed. Thirty-two clinics only sent women the NHSCSP leaflet. No leaflet answered all 38 questions. Less than half (36/100) of the leaflets answered more than 50% of the questions. In addition to the lack of advice given, different leaflets frequently gave conflicting advice. The average Gunning fog score was 9.7 (range 5.5-15.5). The majority of women (70%) wanted to receive information about colposcopy at or prior to the time of receiving their abnormal smear test result, although only 42% of women actually received information at this time.

CONCLUSIONS

Many UK colposcopy clinics do not appear to be providing women with the information they require to understand their condition and the procedure that they are about to undergo. Furthermore, this information is often not provided at the appropriate time in the screening process.

NAAG fails to antagonize synaptic and extrasynaptic NMDA receptors in cerebellar granule neurons

The peptide transmitter N-acetylaspartylglutamate (NAAG) selectively activates the group II metabotropic glutamate receptors. Several reports also suggest that this peptide acts as a partial agonist at N-methyl-D-aspartate (NMDA) receptors but its putative antagonist effects have not been directly tested. To do this, we used whole cell recordings from cerebellar granule cells (CGC) in culture that allow the highest possible resolution of NMDA channel activation. When CGC were activated with equimolar concentrations of NMDA and NAAG, the peptide failed to alter the peak current elicited by NMDA. Very high concentrations of NAAG (100-200 microM) did not significantly reduce the current elicited by 10 microM NMDA or 0.1 microM glutamate, while 400 microM NAAG produced only a very small (less than 15%) reduction in these whole cell currents. Similarly, NAAG (400 microM) failed to significantly alter the average decay time constant or the peak amplitude of NMDA receptor-mediated miniature excitatory post-synaptic currents (mEPSCs). We conclude that high concentrations of the peptide do not exert physiologically relevant antagonist actions on synaptic NMDA receptor activation following vesicular release of glutamate. As an agonist, purified NAAG was found to be at least 10,000-fold less potent than glutamate in increasing "background" current via NMDA receptors on CGC. Inasmuch as it is difficult to confirm that NAAG preparations are completely free from contamination with glutamate at the 0.01% level, the peptide itself appears unlikely to have a direct agonist activity at the NMDA receptor subtypes found in CGC. Recent reports indicate that enhancing the activity of endogenous NAAG may be an important therapeutic approach to excitotoxicity and chronic pain perception. These effects are likely mediated by group II mGluRs, not NMDA receptors.

Can pre-colposcopy sessions reduce anxiety at the time of colposcopy? A prospective randomised study

The main objective of this prospective randomised study was to evaluate whether offering pre-colposcopy group sessions reduces anxiety at the time of colposcopy. We also examined whether this strategy improved knowledge about abnormal smears and colposcopy and improved satisfaction with the colposcopy service provided. One hundred and forty-seven women undergoing colposcopy for the first time were randomised into two groups. The control group (n = 75) received conventional management. The study group (n = 72), in addition to conventional management, were invited to attend a pre-colposcopy group session led by a trained colposcopy nurse. Questionnaires were used to determine state anxiety inventory scores and knowledge scores at the time of randomisation, immediately before colposcopy and 6 weeks after the clinic visit. Satisfaction questionnaires were completed 6 weeks after the clinic visit. We found that women attending colposcopy clinics are anxious. Those women who attended the pre-colposcopy session had improved knowledge scores (P = 0.039) at the time of colposcopy and satisfaction (P = 0.037). However, the intervention failed to significantly reduce anxiety at the time of colposcopy (P > 0.05).

Offering routine antenatal testing for HIV and hepatitis B in the rural setting of Cornwall

Before Department of Health directives to offer HIV and hepatitis B (HBV) testing to all pregnant women, there was little such screening in Cornwall. Through a multiagency collaborative approach a new antenatal screening programme for HIV/HBV has been introduced with high uptake in the first year (HIV 92% and HBV 93%). We also report the findings of a questionnaire survey of community midwives who alone offer antenatal HIV/HBV testing in Cornwall.

Gliomatosis cerebri in a 10-year-old girl masquerading as diffuse encephalomyelitis and spinal cord tumour

Gliomatosis cerebri is the unifying term used when diffuse glial infiltration occurs throughout the cerebral hemispheres. The very few cases reported in children have presented with intractable epilepsy, corticospinal tract deficits, unilateral tremor, headaches, and developmental delay. Antemortem diagnosis is difficult because of the vagueness of the physical, radiological and pathological findings. Adult cases may simulate an acute diffuse encephalomyelitis and show postmortem evidence of a marked swelling of the spinal cord. Apparently benign intracranial hypertension with papilloedema has also been recorded. We report a 10-year-old girl who presented with a history and physical signs suggestive of benign intracranial hypertension. A diffuse encephalomyelopathy occurred, which was complicated by spinal cord swelling, followed by deterioration and death. Gliomatosis cerebri affecting the brain and spinal cord was found at postmortem examination.

Methadone, methadone treatment and non-fatal overdose

This paper provides a mainly qualitative investigation of the role of methadone and methadone treatment in non-fatal illicit drug overdose. During 1997 and 1998, semi-structured interviews were conducted with 33 individuals in six hospital accident and emergency departments in two Scottish cities. The research identified four overdose situations related to methadone/methadone treatment. These were: (1) topping up a legitimate methadone prescription; (2) abusing another's methadone prescription; (3) preferring illegal drugs to prescribed methadone; and (4) failing to obtain prescribed methadone. The implications of these findings for methadone treatment policy and practice are discussed.

Clinical course of a fatal ingestion of diquat

CASE REPORT

A 28-year-old male ingested the herbicide diquat. The patient rapidly developed severe gastrointestinal and metabolic disturbances, airway compromise, respiratory failure, renal failure, hemodynamic collapse, and seizures. We describe multiple metabolic abnormalities, an apparent artifact introduced by diquat in the laboratory assay for serum creatinine, serum diquat levels, and the need for emergency airway management.

Suicidal intent in non-fatal illicit drug overdose

AIM

To explore suicidal intent among drug users experiencing non-fatal overdose.

DESIGN

Semi-structured interviews.

SETTING AND PARTICIPANTS

Seventy-seven drug users experiencing non-fatal overdose and attending six hospital accident and emergency departments in two Scottish cities during 1997 and 1998.

MEASUREMENTS

The extent of suicidal intent and motivations for intentional overdosing were examined.

FINDINGS

The incidence of suicidal intent was high, with 38 respondents (49%) reporting suicidal thoughts or feelings before overdosing. Suicidal actions were significantly associated with a self-reported history of life-time mental health problems and with not using heroin prior to overdosing, but not with other demographic or drug history data. Qualitative data indicated that intentional overdosing was frequently not driven by a clear and unambiguous desire to die. Furthermore, suicidal actions were motivated by a range of psychosocial factors, including: (i) predisposing personal circumstances; (ii) precipitating events; and (iii) poor individual coping strategies.

CONCLUSIONS

The issue of suicidal intent needs to be addressed routinely in hospital wards and accident and emergency departments so that the need for support can be assessed.

Does trait coping exist? A momentary assessment approach to the evaluation of traits

This study investigated the extent to which momentary reports of coping are a traitlike phenomenon and the validity of a questionnaire assessment of coping style. Participants (N = 96) completed the questionnaire, then monitored stressful events and coping activities for 2 days using a hand-held computer that administered a brief assessment every 40 min. Momentary reports exhibited a sizable traitlike component: Individual differences accounted for 42% of the variance for 2 coping items and 15-30% of the variance for 15 items. The questionnaire assessment of coping style was a poor predictor of average momentary coping; the coping style measure and the aggregated momentary measure of trait coping shared 23% of their variance for religion and 0-12% for the 16 other coping measures. Self-report assessments of trait coping are poor measures of the trait component of momentary coping and very poor predictors of coping in specific situations.

Nurse practitioners and physicians: a collaborative practice

The rapid evolution of health care delivery within the United States has created increased opportunities for nurse practitioners (NPs) to work in a variety of challenging advanced practice roles and to impact the quality of health care. The NP role was originally developed to meet a perceived shortage of primary care physicians, especially for underserved populations. Today, NPs work in various fields, such as geriatrics and women's and family health care, as well as in various systems such as private practice and health maintenance organizations. Effective collaboration with physician colleagues will promote improved communication, health care management, and positive health outcomes. Barriers to effective collaboration are reimbursement, territorialism, and role confusion on part of the health care team and the general public.

Does trait coping exist? A momentary assessment approach to the evaluation of traits

This study investigated the extent to which momentary reports of coping are a traitlike phenomenon and the validity of a questionnaire assessment of coping style. Participants (N = 96) completed the questionnaire, then monitored stressful events and coping activities for 2 days using a hand-held computer that administered a brief assessment every 40 min. Momentary reports exhibited a sizable traitlike component: Individual differences accounted for 42% of the variance for 2 coping items and 15-30% of the variance for 15 items. The questionnaire assessment of coping style was a poor predictor of average momentary coping; the coping style measure and the aggregated momentary measure of trait coping shared 23% of their variance for religion and 0-12% for the 16 other coping measures. Self-report assessments of trait coping are poor measures of the trait component of momentary coping and very poor predictors of coping in specific situations.

Rapid identification of metallo- and serine beta-lactamases

Simple methods to detect, identify, and differentiate metallo- and serine beta-lactamases were developed and used to differentiate enzymes produced by 17 clinical isolates of Xanthomonas maltophilia. All isolates exhibited beta-lactamase activity, and in 16 strains this was induced by imipenem. All but one isolate hydrolyzed imipenem (and meropenem), and in all cases this activity was inhibited by 1 mM EDTA. The metallo- and serine beta-lactamases in the cell extracts were distinguished on isoelectric focusing (IEF) gels by using the following procedures. (i) Cell lysates were preincubated with 83 mM EDTA prior to IEF and subsequent visualization with nitrocefin, and (ii) after IEF, the gels were overlaid with either 1 mM zinc sulfate or 100 microM BRL 42715 before staining with nitrocefin. Bands of beta-lactamase activity which were removed by BRL 42715 but unaffected by EDTA or zinc sulfate were categorized as serine beta-lactamases. Bands which were unaffected by BRL 42715 but inhibited by EDTA or enhanced by zinc sulfate were classified as metallo-beta-lactamases. By using this approach, seven metallo-beta-lactamases were differentiated with pI values of 4.8 (two strains), 5.5 (four strains), 5.7 (one strain), 6.0 (one strain), 6.4 (four strains), 6.6 (one strain), and 6.8 (three strains). The metallo-beta-lactamase band with a pI of 6.4 aligned with the recently characterized metallo-beta-lactamase from X. maltophilia 511. Heterogeneity was also observed for the serine beta-lactamases: 14 isolates elaborated serine beta-lactamase activity which focused with major bands with at least eight different pIs. The remaining three strains produced serine beta-lactamases which focused with five distinct bands with pIs of 6.4, 6.2, 5.7, 5.5, and 5.2. We conclude that X. maltophilia produces many types of metallo- and serine beta-lactamases distinguishable by these new methods and that the previously reported L-1 and L-2 enzymes are not solely representative of the beta-lactamases produced by this species.

Poor participation of nulliparous women in a low dose aspirin study to prevent preeclampsia

Only four of 39 nulliparous women agreed to participate in a placebo controlled study of low dose aspirin therapy to prevent preeclampsia. The major reason for nonparticipation was fear the aspirin would harm the fetus (30 of 35 women). Twenty-four women felt public promotion of a healthy lifestyle influenced their nonparticipation. No woman felt any practical problems related to the study impeded their recruitment and all but one woman felt the study was important and worthwhile. Eleven women considered any drug therapy or research in pregnancy was anathema. As a result of the low response rate a multicentered study was not feasible. Unless new approaches to research are developed, scientific advances in obstetric practice in New Zealand may depend only on research conducted overseas.

Actinic prurigo of the lower lip. Review of the literature and report of five cases

Actinic prurigo (AP) is a chronic, familial, photodermatitis that primarily affects American Indians. It is more prevalent in young females and may be evident clinically as a pruritic lower lip cheilitis that typically does not respond to conventional therapy. Other clinical features associated with AP include conjunctivitis, alopecia of the eyebrows, and formation of pterygia. The histologic features of AP have been described as nonspecific. We are presenting five cases of AP in which the major clinical manifestation was a pruritic, unsightly lower lip cheilitis. All of our patients were American Indians. Three patients were from the same family. The youngest patient was 10 years old and the oldest was 69 years old. All five cases were characterized histologically by numerous germinal centers within the lamina propria and a dense perivascular plasma cell infiltrate. In four of the five cases, there was a moderate to dense infiltrate of eosinophils. All five patients had been generally unresponsive to conventional therapy. With the exception of the youngest patient, all had had the disease for at least several years. One patient, now deceased, had the lower lip lesion surgically removed for cosmetic reasons. To our knowledge, this is the first report in the dental literature that describes the clinical and histologic features of AP of lower lip.

Hospital catering: more plates for more patients

Hospitals which increase in size in terms of buildings and beds present problems to catering staff especially when the buildings are a mixture of old and new. Existing facilities are seldom adequate to cope with extended distances between wards or throughput of meals for an increasing number of patients. The Royal Sussex County Hospital at Brighton has solved most of its problems with the opening of a new catering complex described here by John Neale, district catering manager.