Services for pregnant drug users

Drug and alcohol misuse during pregnancy poses a threat to the health of both the developing foetus and the mother yet this complex clinical problem often falls between different stools within the health services. A mother would first have to recognise herself as a drug or alcohol misuser needing help before she came within the ambit of the addiction services. On the other hand, the obstetric agencies, even when they identify a drug problem, usually do not regard themselves as having a role. General practitioners are most likely to have an overall view and therefore to be in the best position to manage the problem. However, many misusers do not register with GPs and, despite calls to the contrary, GPs have not become more widely involved in the management of addiction.

Abstract P5-10-01: Patient advocates as partners in breast cancer research at Georgetown University Lombardi Comprehensive Cancer Center

The integration of patient advocate input into biomedical research grant proposals is a relatively new phenomenon and represents a paradigm shift for basic, translational and clinical researchers seeking funding for their proposed studies. In 2011, the Lombardi Comprehensive Cancer Center (LCCC) at Georgetown University (GU) established the Georgetown Breast Cancer Advocates (GBCA) to facilitate collaboration between researchers and advocates. The mission of GBCA is to ensure research is patient-centered, innovative, evidence-based, and accessible. Working with researchers and clinicians at GU-LCCC early in proposal development, the members of the GBCA evaluate the feasibility of research, emphasizing the need for bench-to-bedside studies, the importance of quality of life, health care disparities and a reduction in breast cancer mortality. This integrated and early approach has resulted in GU-LCCC researchers being awarded a PCORI Grant, a DOD Idea Expansion Award, and a prestigious NIH U01 award.

The GBCA consists of survivors and community stakeholders from diverse ethnic, racial, and age groups. It ranges from women at high risk for breast cancer to both short- and long-term survivors of various sub-types of breast cancer and those with recurrent disease. Several advocates were trained by the National Breast Cancer Coalition's scientific education program, Project LEAD, and others participate in the Susan G. Komen for the Cure Advocates in Science Program. Members have served as consumer reviewers for the DOD's Breast Cancer Research Program at both the peer review and programmatic review levels, and as patient representatives on American Society of Clinical Oncology (ASCO) clinical practice guideline panels. GU-LCCC researchers and oncologists serve as advisors for the group.

This poster describes the evolution and work of the GBCA and how the group has influenced breast cancer research at GU-LCCC. GBCA works with researchers in the pre-award phase, providing input to investigators regarding methodologies to increase participant recruitment, retention, and adherence to research protocols. The advocates also provide input on study designs and patient education strategies. Through their contributions, the advocates have become an integral and respected part of the breast cancer research community at GU-LCCC.

Citation Format: Brundage S, Charles Chisholm D, Holloway JN, Lucas W, Salamone J, Winarsky S, London M, Greenwood N, Stahl S, Carbine N, Goyes R, Price E, Ernst E, Leventhal K-G, Isaacs C, Clarke R, Shajahan-Haq AN. Patient advocates as partners in breast cancer research at Georgetown University Lombardi Comprehensive Cancer Center. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-10-01.

Safety climate and workplace violence prevention in state-run residential addiction treatment centers

OBJECTIVE

To examine the association between violence prevention safety climate measures and self reported violence toward staff in state-run residential addiction treatment centers.

METHODS

In mid-2006, 409 staff from an Eastern United States state agency that oversees a system of thirteen residential addiction treatment centers (ATCs) completed a self-administered survey as part of a comprehensive risk assessment. The survey was undertaken to identify and measure facility-level risk factors for violence, including staff perceptions of the quality of existing US Occupational Safety and Health Administration (OSHA) program elements, and ultimately to guide violence prevention programming. Key informant interviews and staff focus groups provided researchers with qualitative data with which to understand safety climate and violence prevention efforts within these work settings.

RESULTS

The frequency with which staff reported experiencing violent behavior ranged from 37% for "clients raised their voices in a threatening way to you" to 1% for "clients pushed, hit, kicked, or struck you". Findings from the staff survey included the following significant predictors of violence: "client actively resisting program" (OR=2.34, 95% CI=1.35, 4.05), "working with clients for whom the history of violence is unknown" (OR=1.91, 95% CI=1.18, 3.09) and "management commitment to violence prevention" reported as "never/hardly ever" and "seldom or sometimes" (OR=4.30 and OR=2.31 respectively), while controlling for other covariates.

CONCLUSIONS

We utilized a combination of qualitative and quantitative research methods to begin to describe the risk and potential for violence prevention in this setting. The prevalence of staff physical violence within the agency's treatment facilities was lower than would be predicted. Possible explanations include the voluntary nature of treatment programs; strong policies and consequences for resident behavior and ongoing quality improvement efforts. Quantitative data identified low management commitment to violence prevention as a significant predictor of staff reported violence.

Abnormal frontal activations related to decision-making in current and former amphetamine and opiate dependent individuals

RATIONALE

There is converging evidence for impairments in decision-making in chronic substance users. In the light of findings that substance abuse is associated with disruptions of the functioning of the striato-thalamo-orbitofrontal circuits, it has been suggested that decision-making impairments are linked to frontal lobe dysfunction. We sought to investigate this possibility using functional neuroimaging.

METHODS

Decision-making was investigated using the Cambridge Risk Task during H2(15)O PET scans. A specific feature of the Risk Task is the decisional conflict between an unlikely high reward option and a likely low reward option. Four groups, each consisting of 15 participants, were compared: chronic amphetamine users, chronic opiate users, ex-drug users who had been long-term amphetamine/opiate users but are abstinent from all drugs of abuse for at least 1 year and healthy matched controls without a drug-taking history.

RESULTS

During decision-making, control participants showed relatively greater activation in the right dorsolateral prefrontal cortex, whereas participants engaged in current or previous drug use showed relatively greater activation in the left orbitofrontal cortex.

CONCLUSION

Our results indicate a disturbance in the mediation by the prefrontal cortex of a risky decision-making task associated with amphetamine and opiate abuse. Moreover, this disturbance was observed in a group of former drug users who had been abstinent for at least 1 year.

Negative-Pressure monitoring of tuberculosis isolation rooms within New York State hospitals

A previously published study recommended the daily use of visible smoke to test for negative air pressure in isolation rooms occupied by potentially infectious tuberculosis cases. Continuous monitoring devices were found to have poor reliability. Findings from our survey of engineering controls in acute-care hospitals within New York State support this recommendation.

Untangling dendrites with quantitative models

Our understanding of the function of dendrites has been greatly enriched by an inspiring dialogue between theory and experiments. Rather than functionally ignoring dendrites, representing neurons as single summing points, we have realized that dendrites are electrically and chemically distributed nonlinear units and that this has important consequences for interpreting experimental data and for the role of neurons in information processing. Here, we examine the route to unraveling some of the enigmas of dendrites and highlight the main insights that have been gained. Future directions are discussed that will enable theory and models to keep shedding light on dendrites, where the most fundamental input-output adaptive processes take place.

Subthreshold voltage noise due to channel fluctuations in active neuronal membranes

Voltage-gated ion channels in neuronal membranes fluctuate randomly between different conformational states due to thermal agitation. Fluctuations between conducting and nonconducting states give rise to noisy membrane currents and subthreshold voltage fluctuations and may contribute to variability in spike timing. Here we study subthreshold voltage fluctuations due to active voltage-gated Na+ and K+ channels as predicted by two commonly used kinetic schemes: the Mainen et al. (1995) (MJHS) kinetic scheme, which has been used to model dendritic channels in cortical neurons, and the classical Hodgkin-Huxley (1952) (HH) kinetic scheme for the squid giant axon. We compute the magnitudes, amplitude distributions, and power spectral densities of the voltage noise in isopotential membrane patches predicted by these kinetic schemes. For both schemes, noise magnitudes increase rapidly with depolarization from rest. Noise is larger for smaller patch areas but is smaller for increased model temperatures. We contrast the results from Monte Carlo simulations of the stochastic nonlinear kinetic schemes with analytical, closed-form expressions derived using passive and quasi-active linear approximations to the kinetic schemes. For all subthreshold voltage ranges, the quasi-active linearized approximation is accurate within 8% and may thus be used in large-scale simulations of realistic neuronal geometries.

Profiles of cognitive dysfunction in chronic amphetamine and heroin abusers

Groups of subjects whose primary drug of abuse was amphetamine or heroin were compared, together with age- and IQ-matched control subjects. The study consisted of a neuropsychological test battery which included both conventional tests and also computerised tests of recognition memory, spatial working memory, planning, sequence generation, visual discrimination learning, and attentional set-shifting. Many of these tests have previously been shown to be sensitive to cortical damage (including selective lesions of the temporal or frontal lobes) and to cognitive deficits in dementia, basal ganglia disease, and neuropsychiatric disorder. Qualitative differences, as well as some commonalities, were found in the profile of cognitive impairment between the two groups. The chronic amphetamine abusers were significantly impaired in performance on the extra-dimensional shift task (a core component of the Wisconsin Card Sort Test) whereas in contrast, the heroin abusers were impaired in learning the normally easier intra-dimensional shift component. Both groups were impaired in some of tests of spatial working memory. However, the amphetamine group, unlike the heroin group, were not deficient in an index of strategic performance on this test. The heroin group failed to show significant improvement between two blocks of a sequence generation task after training and additionally exhibited more perseverative behavior on this task. The two groups were profoundly, but equivalently impaired on a test of pattern recognition memory sensitive to temporal lobe dysfunction. These results indicate that chronic drug use may lead to distinct patterns of cognitive impairment that may be associated with dysfunction of different components of cortico-striatal circuitry.

Group and case study of the dysexecutive syndrome in alcoholism without amnesia

OBJECTIVES

To test the dysexecutive syndrome (DES) hypothesis of chronic alcoholism by the neuropsychological group and case study approaches.

METHODS

A comprehensive neuropsychological assessment, including the "behavioural assessment of dysexecutive syndrome", a battery of tests recently designed to be "ecologically valid", was administered to 17 patients with chronic alcoholism without amnesia to examine executive functions, intelligence, and memory. In terms of each neuropsychological measure, reciprocal analyses of group means and individual case profiles were conducted: for the first contrasting the alcoholic patients with 17 age matched healthy subjects; and for the second making intersubject and intrasubject comparison of the patients, according to percentile basis impairment indices obtained from the control subjects.

RESULTS

Despite relatively unimpaired memory and intelligence, the patients as a whole had the impairment of a wide range of executive domains, extending to "everyday" problem solving as well as more elementary aspects of executive functions, such as visuospatial performance, mental set shifting, and the inhibition of habitual behaviour. The profile analysis divided individual patients into four groups: the representative DES characterised by a clear dissociation between impaired executive functions and preserved intelligence and memory; the group of a modified dysexecutive pattern in which memory as well as executive functions were impaired with intelligence preserved; the group of general cognitive deterioration; and the group of unimpaired cognitive functioning. About two thirds of the patients were categorised into either the first or the second type of DES.

CONCLUSION

DES characterised by the even more pronounced impairment of executive functions than of intelligence and memory afflicts a considerable proportion of patients with chronic alcoholism. Due to its subtlety, this would be potentially left out, unless appropriate behavioural measures were administered. This condition may prevent patients with alcoholism from achieving full recovery and benefiting from rehabilitation.

Identification of factors that disrupt negative air pressurization of respiratory isolation rooms

OBJECTIVES

To investigate the airflow characteristics of respiratory isolation rooms (IRs) and to evaluate the use of visible smoke as a monitoring tool.

METHODS

Industrial hygienists from the New York State Department of Health evaluated 140 designated IRs in 38 facilities within New York State during 1992 to 1998. The rooms were located in the following settings: hospitals (59%), correctional facilities (40%), and nursing homes (1%). Each room was tested with visible smoke for directional airflow into the patient room (ie, negative air pressure relative to adjacent areas). Information was obtained on each facility's policies and procedures for maintaining and monitoring the operation of the IRs.

RESULTS

Inappropriate outward airflow was observed in 38% of the IRs tested. Multiple factors were associated with outward airflow direction, including ventilation systems not balanced (54% of failed rooms), shared anterooms (14%), turbulent airflow patterns (11%), and automated control system inaccuracies (10%). Of the 140 tested rooms, 38 (27%) had either electrical or mechanical devices to monitor air pressurization continuously. The direction of airflow at the door to 50% (19/38) of these rooms was the opposite of that indicated by the continuous monitors at the time of our evaluations. The inability of continuous monitors to indicate the direction of airflow was associated with instrument limitations (74%) and malfunction of the devices (26%). In one facility, daily smoke testing by infection control staff was responsible for identifying the malfunction of a state-of-the-art computerized ventilation monitoring and control system in a room housing a patient infectious with drug-resistant tuberculosis.

CONCLUSION

A substantial percentage of IRs did not meet the negative air pressure criterion. These failures were associated with a variety of characteristics in the design and operation of the IRs. Our findings indicate that a balanced ventilation system does not guarantee inward airflow direction. Devices that continuously monitor and, in some cases, control the pressurization of IRs had poor reliability. This study demonstrates the utility of using visible smoke for testing directional airflow of IRs, whether or not continuous monitors are used. Institutional tuberculosis control pro grams should include provisions for appropriate monitoring and maintenance of IR systems on a frequent basis, including the use of visible smoke.

Signal transfer in passive dendrites with nonuniform membrane conductance

In recent years it became clear that dendrites possess a host of ion channels that may be distributed nonuniformly over their membrane surface. In cortical pyramids, for example, it was demonstrated that the resting membrane conductance G(m)(x) is higher (the membrane is "leakier") at distal dendritic regions than at more proximal sites. How does this spatial nonuniformity in G(m)(x) affect the input-output function of the neuron? The present study aims at providing basic insights into this question. To this end, we have analytically studied the fundamental effects of membrane non-uniformity in passive cable structures. Keeping the total membrane conductance over a given modeled structure fixed (i.e., a constant number of passive ion channels), the classical case of cables with uniform membrane conductance is contrasted with various nonuniform cases with the following general conclusions. (1) For cylindrical cables with "sealed ends," monotonic increase in G(m)(x) improves voltage transfer from the input location to the soma. The steeper the G(m)(x), the larger the improvement. (2) This effect is further enhanced when the stimulation is distal and consists of a synaptic input rather than a current source. (3) Any nonuniformity in G(m)(x) decreases the electrotonic length, L, of the cylinder. (4) The system time constant tau(0) is larger in the nonuniform case than in the corresponding uniform case. (5) When voltage transients relax with tau(0), the dendritic tree is not isopotential in the nonuniform case, at variance with the uniform case. The effect of membrane nonuniformity on signal transfer in reconstructed dendritic trees and on the I/f relation of the neuron is also considered, and experimental methods for assessing membrane nonuniformity in dendrites are discussed.

Dissociable deficits in the decision-making cognition of chronic amphetamine abusers, opiate abusers, patients with focal damage to prefrontal cortex, and tryptophan-depleted normal volunteers: evidence for monoaminergic mechanisms

We used a novel computerized decision-making task to compare the decision-making behavior of chronic amphetamine abusers, chronic opiate abusers, and patients with focal lesions of orbital prefrontal cortex (PFC) or dorsolateral/medial PFC. We also assessed the effects of reducing central 5-hydroxytryptamine (5-HT) activity using a tryptophan-depleting amino acid drink in normal volunteers. Chronic amphetamine abusers showed suboptimal decisions (correlated with years of abuse), and deliberated for significantly longer before making their choices. The opiate abusers exhibited only the second of these behavioral changes. Importantly, both sub-optimal choices and increased deliberation times were evident in the patients with damage to orbitofrontal PFC but not other sectors of PFC. Qualitatively, the performance of the subjects with lowered plasma tryptophan was similar to that associated with amphetamine abuse, consistent with recent reports of depleted 5-HT in the orbital regions of PFC of methamphetamine abusers. Overall, these data suggest that chronic amphetamine abusers show similar decision-making deficits to those seen after focal damage to orbitofrontal PFC. These deficits may reflect altered neuromodulation of the orbitofrontal PFC and interconnected limbic-striatal systems by both the ascending 5-HT and mesocortical dopamine (DA) projections.

An On-line agglomerative clustering method for nonstationary data

An on-line agglomerative clustering algorithm for nonstationary data is described. Three issues are addressed. The first regards the temporal aspects of the data. The clustering of stationary data by the proposed algorithm is comparable to the other popular algorithms tested (batch and on-line). The second issue addressed is the number of clusters required to represent the data. The algorithm provides an efficient framework to determine the natural number of clusters given the scale of the problem. Finally, the proposed algorithm implicitly minimizes the local distortion, a measure that takes into account clusters with relatively small mass. In contrast, most existing on-line clustering methods assume stationarity of the data. When used to cluster nonstationary data, these methods fail to generate a good representation. Moreover, most current algorithms are computationally intensive when determining the correct number of clusters. These algorithms tend to neglect clusters of small mass due to their minimization of the global distortion (Energy).

Silo gas exposure in New York state following the dry growing season of 1995

Exposure to silo gas is a recognized agricultural hazard. Silo gas produced from corn fermentation may consist of oxides of nitrogen and carbon dioxide. The presence of potentially lethal concentrations of nitrogen dioxide (NO2) within vertical silos has been well documented. The risk of silo gas exposure from other silage storage methodologies--including horizontal "ag-bags" and concrete bunkers--has been less well characterized. A dry growing season is known to be a factor for elevating nitrate levels in corn plants and can result in increased NO2 production. Farms in the northeastern United States faced drought conditions during the 1995 growing season. The New York State (NYS) Department of Health (DOH) and the New York Center for Agricultural Medicine and Health (NYCAMH) investigated four exposure incidents involving six farmworkers during September/October 1995. Four of these workers were hospitalized for multiple days, with two workers receiving treatment in intensive care units. The remaining two workers were treated in hospital emergency departments; one refused admission and left against medical advice. We monitored NO2 levels from "ag-bags" at several New York farms. For four days, outdoor concentrations of NO2 at one site remained in excess of the National Institute for Occupational Safety and Health's (NIOSH) immediately dangerous to life and health value (IDLH) of 20 ppm. As a result of the clinical and industrial hygiene data, and the growing season's abnormal weather conditions, DOH and NYCAMH issued statewide health hazard alerts and conducted educational activities to warn farmers and their families. The findings of this study reinforce the potential hazards associated with silo gas exposure and identify the use of ag-bags as a relatively new avenue for significant worker exposure.

Nitrate levels in drinking water in rural New York State

To obtain an indication of the nitrate-nitrogen levels in drinking water in rural areas of upstate New York and the number of infants at risk for methemoglobinemia, 419 wells supplying drinking water to farms were tested. Farmers were identified through two programs run by the New York State Department of Health. The farmers were asked to complete a short questionnaire about the type and size of their farm and their well and to collect the water sample. Overall, nitrates were detectable in 95% of the wells tested (concentration levels greater than 0.05 mg/L) and 15.7% had levels which exceeded 10 mg/L. Fifteen percent of the wells tested from farms where infants resided were also elevated. Wells which were shallow, dug or located on large farms, or springs were more likely to have elevated concentrations of nitrates.

Enhancing the identification of excessive drinkers on medical wards: a 1-year follow-up study

This paper describes a 1-year follow-up study examining whether hospital ward doctors and nurses continue to take quantitative alcohol histories and provide brief intervention to problem drinkers on general medical wards after the introduction of a simple protocol. Regular training in the use of this protocol was stipulated in the annual service contract between the Health Authority and the Hospital Trusts. Improvements in staff practice persisted at 1-year follow-up, although it fell from a peak at an earlier phase of the study. The positive role of state purchasers of health services in sustaining improvements in clinical practice is discussed.

Farm worker injuries associated with cows. New York State 1991-1996

1. The size of cows and their unpredictable behavior constitute a hazard for workers who handle them. 2. When cows are startled by sudden movements and unfamiliar situations, they may kick, push, knock down, fall, or step on workers. 3. Cows in heat or those with calves are particularly excitable. Working in confining situations, such as milking stalls, exacerbates the danger of injury to handlers. 4. Knowledge of effective animal handling techniques and well designed handling facilities can reduce the incidence of injury.

Farm worker injuries associated with bulls. New York State 1991-1996

1. Although cows greatly outnumber bulls on dairy farms, bulls account for 25% of animal related injuries in a surveillance study of agricultural injury. In addition, bull injuries are more severe. 2. Because of their size and unpredictable behavior, bulls, especially those over 18 months of age, must be handled with extreme caution. 3. Important risk factors for the observed incidents were working alone and not having an escape route. 4. Bulls should be dehorned and confined in specially designed facilities to avoid human contact during feeding, watering, exercising, or breeding.

Non-covalent associations of proteins in plasma: self-, mixed fibrin(ogen), mixed protein-non-protein associations

OBJECTIVE

To review biochemical literature and determine the significance of non-covalent bonding in plasma.

RESULTS

Many non-covalent bonds exist in plasma. Relatively strong self-associations are found for serum albumin, several gamma-globulins, apolipoproteins and fibrin(ogen). Here, fibrinogen and fibrin, considered one specie, react with other blood entities, building structures in plasma. A surface phenomenon analogous to viscosity is described for fibrin(ogen) which is useful in studying bonding. Combinations of lipids, proteins, polysaccharides and cellular elements form mixed associations. They add to the variety and number of non-covalent associations of proteins. Lipids make fairly strong associations.

CONCLUSIONS

Fibrinogen binding may play a major role in organizing blood to develop primitive structure. Lipids too may add to forming large structures. Non-covalent bonds are very common in plasma, and blood may have to be considered as a quasi-structured tissue.

The role of blood rheology in regulating blood pressure

Review of the role of blood rheology in regulating blood pressure discloses that macromolecular binding to the erythrocyte membrane is a significant factor. Evidence is summarized supporting the thesis that blood viscosity is a prime regulator of blood pressure. Macromolecules may bind to erythrocytes and other macromolecules forming structures that increase blood viscosity when the blood stream flow rate is decreased. Review of the nature and extent of RBC membrane binding and a model for relating these bonds to blood pressure are presented.

MR angiography with an ultrasmall superparamagnetic iron oxide blood pool agent

The purpose of the study was to investigate the use of a dextran-coated ultrasmall superparamagnetic iron oxide (USPIO) as a blood pool contrast agent for thoracic and abdominal MR angiography. Abdominal and thoracic MR angiography was performed in six healthy volunteers using two-dimensional and three-dimensional spoiled gradient echo (SPGR) sequences before and after intravenous administration of USPIO. Doses ranged from 1.1 to 2.6 mg Fe/kg. Flip angle was varied from 20 to 60 degrees. Subjective image quality, analysis of signal-to-noise ratio (SNR), and blood T1 relaxation times were measured. USPIO significantly lowered the T1 of blood (from 1,210 ms precontrast to 159 ms postcontrast at a dose of 2.6 mg Fe/kg) (P < .01). Image quality on coronal fast three-dimensional breath-hold SPGR images of the abdomen increased with increasing dose and was maximum at the highest dose, producing an aortic SNR of 9.6 compared to 1.8 precontrast. Axial two-dimensional time-of-flight (TOF) aortic SNR was reduced significantly from 13 on precontrast to 6 on the postcontrast images at the highest dose (P < .05) due to T2* shortening effects. There was little flip angle dependence on image quality. Due to the T1 shortening effect and long intravascular half-life, USPIO improved visualization of vascular anatomy using three-dimensional fast SPGR imaging. The echo time must be minimized to minimize signal loss from T2* shortening effects. The blood pool distribution of USPIO is useful for equilibrium-phase MR angiography.

Occupational and environmental medicine in New York State

New York State (NYS) is home to 7.2% of the population and producer of 8.4% of the gross domestic product of the United States. The history and the current status of occupational and environmental medicine (OEM) research, educational resources, clinical practice patterns, and regulatory framework in NYS are reviewed. Changes anticipated or already taking place in health care financing, clinical practice patterns, occupational safety and health regulations and enforcement, and funding for research and medical education at the national level, are already having an impact in OEM activities in NYS.

Do cage scores predict readiness to reduce alcohol consumption in medical in-patients?

Four-hundred-and-twenty-three medical in-patients received the CAGE, brief Michigan Alcohol Screening Test (MAST) and Readiness to Change (RCQ) questionnaires. Those positive on the CAGE and MAST were more likely to be in contemplation and action phases of the RCQ, suggesting that simple questionnaires identify patients who not only have drinking problems but are ready to make changes to combat them.

Education and audit can improve the identification of excessive drinkers among medical inpatients

This study investigated the effect of education and audit on the identification and management of medical inpatients with excessive alcohol consumptions by use of a cross-sectional survey of medical and nursing notes, compared with historical controls. We report the proportion of medical and nursing notes containing qualitative and quantitative drinking histories, the use of the CAGE questionnaire, and notification of alcohol consumption in discharge summaries. A total of 1,979 out of 2,680 (74%) notes of eligible patients were examined. The number of medical notes containing quantitative alcohol histories rose from 175/792 (22%) among historical controls, to 242/690 (35%) after training of junior medical and nursing staff, and to 241/497 (48%) after feedback of results in a clinical audit meeting. The number of medical notes with no recorded alcohol history changed from 309/792 (39%) to 287/690 (42%) to 152/497 (31%), respectively (chi 2 for trend = 97.2, p < 0.0001). The number of nursing notes containing quantified alcohol histories rose from 31/792 (4%) among historical controls, to 123/690 (18%) after training, and to 237/497 (48%) after feedback of results in a clinical audit meeting. The number of nursing notes with no recorded alcohol history fell from 309/792 (90%), to 512/690 (74%), to 205/497 (41%) respectively (chi 2 for trend = 353.7, p < 0.0001). The proportion of patients found to be drinking excessively rose from 40/792 (5.1%) to 57/690 (8.3%) to 45/497 (9.1%) (chi 2 for trend = 8.25, p = 0.004). There was little worthwhile improvement in use of the CAGE questionnaire and in discharge summaries. Education and audit are effective ways of improving the identification of excessive drinkers by both junior doctors and nurses alike. Other aspects of management are less responsive.

Control of tuberculosis in the workplace: engineering controls

In this review of engineering controls that can be used to check the spread of tuberculosis in health care settings, the authors address types of ventilation and supplements to ventilation such as HEPA filtration and ultraviolet germicidal irradiation. They also specifically cover engineering controls for use during medical procedures that pose an increased risk for transmission of TB.

Use of balloon-expandable stents to treat experimental peripheral pulmonary artery and superior vena caval stenosis: preliminary experience

Current therapy of congenital or acquired stenoses of the peripheral pulmonary arteries and superior vena cava are frequently ineffective. This report describes our initial experience with the use of a balloon-expandable stainless steel stent to treat experimentally created branch pulmonary artery and superior vena cava stenosis. Fifteen adult mongrel dogs had surgically created stenoses of either a branch pulmonary artery and/or superior vena cava. A balloon-expandable stainless steel (0.076 mm), 3 cm long, intravascular stent was used in all animals. Stents were successfully placed in 13 of 15 dogs (nine with branch pulmonary stenosis and four with superior vena caval stenosis) with hemodynamic and angiographic relief of the stenoses in all. In three animals, successful stent placement was not accomplished because the distal right pulmonary artery was found to be totally obstructed in two and in one dog with combined vena cava and pulmonary stenosis the distal right pulmonary artery was so severely stenotic that the stenosis could not be crossed. Repeat catheterization performed 6 months following stent placement documented persistent gradient relief and angiographic evidence of unobstructed flow through the stent without thrombus formation and with patent side branch vessels. Our preliminary results suggests that balloon-expandable stents are a potential therapy for the treatment of branch pulmonary artery and superior vena cava stenoses.

Poppy tea drinking in East Anglia

Poppy tea drinking was a widespread traditional practice in the Fenlands of East Anglia during the nineteenth century. The subsequent social changes which led to greater integration of the area with the rest of the country may have contributed to a decline in the practice. In recent years poppy tea drinking has been revived within the illicit drug using community and a survey using a self-report questionnaire was carried out among patients attending the Cambridge Drug Dependency Unit. Forty-three patients admitted to drinking poppy tea, usually during the summer months and on an intermittent basis. The potency of the infusion varied and was unpredictable but in general was low. Although poisoning from herbicides and pesticides was seen as the main risk, it is in the main perceived by drug users as a harmless secondary activity existing alongside the more regular and more potent drugs of misuse.

Types of opiate addiction and notification to the home office

Hospitalised drug addicts were categorised according to the time lapse between onset of their opiate abuse and their first notification to the Home Office. Late notification correlated with a lower level of dependence, a more intermittent pattern of misuse, and a greater likelihood of alcohol abuse. It is postulated that there may be two types of addiction which lie along a continuum.

Comparison of the trabecular and cortical tissue moduli from human iliac crests

The purpose of this study was to design a method to produce and test mechanically microspecimens of trabecular and cortical tissue from human iliac crests, and compare their measured moduli. Rectangular beam specimens were prepared on a low-speed diamond blade saw and a miniature milling machine. The final specimen dimensions ranged from approximately 50-200 microns for base and height. The modulus of each specimen was measured using three-point bending tests across a span length of 1.04 mm and performed at a constant rate of displacement. A subset of specimens was recovered for a radiographic estimation of degree of mineralization. The results showed the mean trabecular tissue modulus of all iliac crest specimens to be 3.81 GPa, whereas cortical tissue specimens averaged 4.89 GPa. This was a significant difference according to a two-way analysis of variance that controlled for differences between donors. No strong correlations were found between modulus and mineral density. Future investigations that consider other microstructural characteristics and their contributions to modulus, and specimen size effects, are indicated.

Clinical and immunologic studies among egg-processing workers with occupational asthma

Twenty-five workers in an egg-processing factory were evaluated for respiratory sensitization to inhaled egg proteins by a physician evaluation, serial peak expiratory flow rate (PEFR) measurements for a 1-week period, and immunologic tests. Immunologic studies included skin prick tests, serum-specific IgE (RAST), and specific IgG (ELISA) to solutions prepared from commercial food allergens: factory-powdered egg white and yolk products and purified egg white fractions, including ovalbumin, ovomucoid, lysozyme, and conalbumin. Six workers had significant daily PEFR lability (greater than 20%) of whom five had associated cutaneous reactivity to at least one egg allergen. A diagnosis of "definite asthma" was established in five workers suspected by the physician of having asthma. These five workers exhibited significant decrements in daily PEFR that were accompanied by bronchial symptoms. Occupational asthma was diagnosed by the physician in four of the five latter workers. Definite asthma was significantly associated with both cutaneous reactivity to egg allergens (p less than 0.01) and RAST binding (p less than 0.01). Of eight workers with cutaneous reactivity to at least one egg reagent, four workers (50%) were positive to only purified egg white fractions. The highest levels of RAST binding were detected in four workers, and the best binding activity was to ovomucoid and ovalbumin fractions. Elevated specific IgG responses were significantly higher in egg-factory workers to whole egg (p less than 0.005), lysozyme (p less than 0.002), and conalbumin (p less than 0.002) allergens compared to responses of nonexposed control subjects. However, no differences in specific IgG were detected between symptomatic and asymptomatic workers.(ABSTRACT TRUNCATED AT 250 WORDS)

In-patient treatment for drug abuse

During 1984 there were 253 admissions to the in-patient drug dependence treatment unit at Tooting Bec Hospital. Of the 198 patients responsible for these admissions, 60% were male and 43% were over the age of 30 years. There were 151 patients admitted for opiate detoxification, and 75% completed the withdrawal schedule. However, only 15 out of 25 patients admitted for benzodiazepine withdrawals were found to be physically dependent. Other reasons for admission included stabilisation of the dose of opiate (24%) and the treatment of physical complications of addiction.

Occupational asthma from inhaled egg protein

We evaluated workers and performed an industrial hygiene assessment at a plant where raw eggs are processed into powdered egg yolk and whole egg. Egg dust levels in the packaging room straddled the American Conference of Governmental Industrial Hygienists' (ACGIH) exposure guideline of 10 mg/m3 for nuisance dust. We obtained medical histories from 25 workers, and performed physical examinations, spirometry, and serial determinations of peak expiratory flow rate (PEFR) by portable meter every 3 hrs (while awake) for 7 days. We defined symptomatic bronchial lability to be a decrement in PEFR on any one day of 20% or more of the day's maximum, with concurrent symptoms. Skin-prick tests and serum assays for specific IgE by the radioallergosorbent (RAST) method were performed to assess sensitivity to commercial egg proteins, egg protein fractions, and freshly prepared extracts of whole egg powder and yolk. We classified participants as definite cases of asthma if both the examining physician diagnosed asthma and symptomatic bronchial lability was demonstrated by serial PEFR determinations. Definite noncases of asthma were those participants in whom the physician did not diagnose asthma and in whom symptomatic bronchial lability was not demonstrated by PEFR. All five definite cases, compared to three of 16 definite noncases of asthma, had one or more positive skin-prick tests to egg proteins. Four of five cases, compared to 0 of 14 noncases, who had serum determinations, had an elevated RAST to one or more of the egg proteins. This study demonstrates that occupational asthma associated with IgE-mediated allergy to egg proteins occurs among workers exposed to inhaled egg proteins.

Munchausen's syndrome and drug dependence

A man with Munchausen's syndrome was treated for drug dependence, which allowed him to establish and sustain a bond with a hospital, but eventually brought about an ethical dilemma.

Mental illness among immigrant minorities in the United Kingdom

Cross-cultural studies on immigrants from Pakistan and the New Commonwealth are reviewed, with emphasis on epidemiology and differences in clinical presentation. Their referral to the psychiatric service is also examined and deficiencies are noted. Awareness of transcultural issues among health professionals need to be increased in order to achieve diagnosis and improvements in health care.