Prevalence of urinary tract cancer in the Spanish cohort of the IDENTIFY study

INTRODUCTION

Malignant tumors of the urinary tract are associated with high morbidity and mortality, and their prevalence can vary worldwide. Recently, the IDENTIFY study has published results on the prevalence of urinary tract cancer at a global level. This study evaluates the prevalence of cancer within the Spanish cohort of the IDENTIFY study to determine whether the published results can be extrapolated to our population.

PATIENTS AND METHODS

An analysis of the data from the Spanish cohort of patients in the IDENTIFY study was performed. This is a prospective cohort of patients referred to secondary care with suspected cancer, predominantly due to hematuria. Patients were recruited between December 2017 and December 2018.

RESULTS

A total of 706 patients from 9 Spanish centers were analyzed. Of these, 277 (39.2%) were diagnosed with cancer: 259 (36.7%) bladder cancer, 10 (1.4%) upper tract urothelial carcinoma, 9 (1.2%) renal cancer and 5 (0.7%) prostate cancer. Increasing age (OR 1.05 (95% CI 1.03-1.06; P < 0.001)), visible hematuria (VH) OR 2.19 (95% CI 1.13-4.24; P = 0.02)) and smoking (ex-smokers: OR 2.11(95% CI 1.30-3.40; P = 0.002); smokers: OR 2.36 (95% CI 1.40-3.95; P = 0.001)) were associated with higher probability of bladder cancer.

CONCLUSION

This study highlights the risk of bladder cancer in patients with VH and smoking habits. Bladder cancer presented the highest prevalence; higher than the prevalence reported in previous series and presented in the IDENTIFY study. Future work should evaluate other associated factors that allow us to create cancer prediction models to improve the detection of cancer in our patients.

Prevalence and factors associated with polydrug use among clients seeking treatment for alcohol misuse

INTRODUCTION

The aim of this paper was to examine the client and psychosocial characteristics associated with polydrug use in patients with alcohol misuse as their primary drug of concern (PDC) seeking treatment from substance use treatment centres.

METHODS

Self-report surveys were undertaken with clients attending 1 of 34 community-based substance use treatment centres across Australia with alcohol as their PDC. Survey items included client's socio-demographic characteristics, level of alcohol dependence, use of other drugs including tobacco, health and wellbeing factors including health-related quality of life. The factors associated with polydrug use (alcohol use concurrent with at least one other drug) were examined.

RESULTS

In a sample of 1130 clients seeking treatment primarily for alcohol problems, 71% reported also using another drug. The most frequently used drug was tobacco (50%) followed by cannabis (21%) and benzodiazepines (15%). Excluding tobacco use, 35% of participants reported polydrug use. Factors associated with any polydrug use were younger age, lower education levels, lower levels of mental health related quality of life and housing risk (i.e., risk of eviction or experienced homelessness in past 4 weeks). When tobacco was excluded, factors associated with polydrug use were age, lower physical and mental health-related quality of life, and housing risk.

DISCUSSION AND CONCLUSIONS

Most adults seeking treatment for alcohol misuse as their PDC reported using another drug in addition to alcohol. Treatment services should be designed accordingly to maximise the likelihood of treatment engagement and success.

'It's a fragile open door'-enhancing COVID-19 vaccination rates in people receiving treatment for substance use disorder

BACKGROUND

People with substance use disorder are at high risk of harms from COVID-19 infection. Vaccine hesitancy is common in this population and compounds pre-existing barriers to accessing health care. A drug and alcohol service in Sydney, Australia introduced strategies to enhance COVID-19 vaccination in people receiving opioid agonist treatment (OAT). We report vaccination outcomes and staff experiences of this.

METHODS

This mixed methods study (i) retrospectively evaluated vaccine uptake in people accessing OAT and (ii) explored perceptions of staff who delivered vaccination interventions through surveys and semi-structured interviews.

RESULTS

Of the 984 patients receiving OAT on 9 December 2021, 90.9% had received the first COVID-19 vaccination and 86.7% the second. Australia wide vaccination rates on that date were 93.1% and 88.7% for first and second doses, respectively. Staff commented that having a deep knowledge, understanding and connection with the patient group drove implementation and success of vaccination interventions. This was further supported by staff engagement with the vaccination interventions, and communication and sharing information, both between staff and with patients.

CONCLUSION

High rates of COVID-19 vaccination can be achieved in a vulnerable population. Engaged staff providing information and facilitating access to healthcare underpin this success.

Correlates of treatment engagement and client outcomes: results of a randomised controlled trial of nabiximols for the treatment of cannabis use disorder

INTRODUCTION AND AIMS

There is increasing interest and evidence for the use of cannabinoid medications in the treatment of cannabis use disorder, but little examination of the correlates of successful treatment. This paper is a secondary analysis of a randomised placebo-controlled trial of nabiximols for the treatment of cannabis use disorder (CUD), aiming to identify which client and treatment characteristics impact treatment engagement and outcomes.

METHOD

Bayesian multiple regression models were used to examine the impact of age, gender, duration of regular cannabis use, daily quantity of cannabis, cannabis use problems, self-efficacy for quitting, sleep, mental health, pain measures, and treatment group upon treatment engagement (retention, medication dose, and counselling participation) and treatment outcomes (achieving end-of-study abstinence, and a 50% or greater reduction in cannabis use days) among the 128 clients participating in the 12-week trial.

RESULTS

Among the treatment factors, greater counselling attendance was associated with greater odds of abstinence and ≥ 50% reduction in cannabis use; nabiximols with greater odds of ≥ 50% reduction and attending counselling, and reduced hazard of treatment dropout; and higher dose with lower odds of ≥ 50% reduction. Among the client factors, longer duration of regular use was associated with higher odds of abstinence and 50% reduction, and lower hazard of treatment dropout; greater quantity of cannabis use with reduced hazard of dropout, greater odds of attending counselling, and higher average dose; greater pain at baseline with greater odds of ≥ 50% reduction and higher average dose; and more severe sleep issues with lower odds of ≥ 50% reduction. Males had lower odds of attending counselling.

DISCUSSIONS AND CONCLUSIONS

These findings suggest that counselling combined with agonist pharmacotherapy may provide the optimal treatment for cannabis use disorder. Younger clients, male clients, and clients with sleep issues could benefit from extra support from treatment services to improve engagement and outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12616000103460) https://www.anzctr.org.au.

Mood, sleep and pain comorbidity outcomes in cannabis dependent patients: Findings from a nabiximols versus placebo randomised controlled trial

BACKGROUND

Mood, sleep and pain problems are common comorbidities among treatment-seeking cannabis-dependent patients. There is limited evidence suggesting treatment for cannabis dependence is associated with their improvement. This study explored the impact of cannabis dependence treatment on these comorbidities.

METHODS

This is a secondary analysis from a 12-week double-blind placebo-controlled trial testing the efficacy of a cannabis agonist (nabiximols) against placebo in reducing illicit cannabis use in 128 cannabis-dependent participants. Outcome measurements including DASS-21 (Depression, Anxiety, and Stress subscales); Insomnia Severity Index (ISI); and Brief Pain Inventory (BPI), were performed at weeks 0, 4, 8, 12 and 24. Each was analysed as continuous outcomes and as binary cases based on validated clinical cut-offs.

RESULTS

Among those whose DASS and ISI scores were in the moderate to severe range at baseline, after controlling for cannabis use, there was a gradual decrease in severity of symptoms over the course of the trial. BPI decreased significantly until week 12 and then rose again in the post-treatment period during weeks 12-24. Neither pharmacotherapy type (nabiximols vs placebo) nor number of counselling sessions contributed significant explanatory power to any of the models and were excluded from the final analyses for both continuous and categorical outcomes.

CONCLUSIONS

Participants in this trial who qualified as cases at baseline had elevated comorbidity symptoms. There was no evidence that nabiximols treatment is a barrier to achieving reductions in the comorbid symptoms examined. Cannabis dependence treatment reduced illicit cannabis use and improved comorbidity symptoms, even when complete abstinence was not achieved.

92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

Introduction

Diagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.

Method

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.

Results

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.

Conclusions

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

Assessing the concurrent validity, inter-rater reliability and test-re-test reliability of the Australian Treatment Outcomes Profile (ATOP) in alcohol and opioid treatment populations

BACKGROUND AND AIMS

The Australian Treatment Outcomes Profile (ATOP) is a brief instrument measuring recent substance use, risk profile and general health and wellbeing among clients attending alcohol and other drug (AoD) treatment services. This study evaluates the ATOP for concurrent validity, inter-rater and test-re-test reliability among alcohol and opioid treatment groups.

DESIGN

For concurrent validity and inter-rater reliability, participants completed an ATOP with a clinician and an ATOP plus standardized questionnaires (time-line follow-back, Opiate Treatment Index, Kessler-10, 12-item Short Form Survey, World Health Organization Quality of Life-BREF, Personal Wellbeing Index) with a researcher within 3 days. For test-re-test reliability, participants completed two ATOPs with a researcher within a 3-day interval.

SETTING

Outpatient AoD treatment centres in Australia.

PARTICIPANTS

For testing concurrent validity and inter-rater reliability, 278 participants were recruited by advertisements in waiting-rooms or clinician invitation during 2016 to 2018. A further 94 participants were recruited to examine test-re-test reliability.

MEASUREMENTS

Statistical tests used for concurrent validity and test-re-test reliability were Pearson's and Spearman's rank order correlations for continuous variables, and Cohen's κ for nominal variables. Inter-rater reliability was assessed using Krippendorf's α.

FINDINGS

Most Australian Treatment Outcomes Profile items returned excellent or moderate validity and reliability. For the main substances used-alcohol, cannabis and benzodiazepines-concurrent validity, inter-rater reliability and test-re-test reliability all reached excellent or good agreement (0.72-0.96). Psychological health, physical health and quality of life showed fair to strong agreement with their comparator scales (0.47-0.85).

CONCLUSIONS

The Australian Treatment Outcomes Profile is a validated and reliable instrument for assessing recent substance use and clinical risk, health and welfare among alcohol and opioid clients in alcohol and other drug treatment settings. Its ability to reliably measure complex constructs, such as psychological and physical health, against longer scales makes it suitable for integration into routine clinical care, enabling regular monitoring of patient outcomes and safety parameters.

A Brief History of Ebolavirus Disease: Paving the Way Forward by Learning from the Previous Outbreaks

In this review, Ebolavirus Disease (EVD) outbreaks have been comprehensively reviewed from their beginning until now. It chronologically discusses how each outbreak was tackled, national and international actions taken, diagnostic methods applied, the infection control procedures put in place, and the lessons learnt from each epidemic for the control of subsequent epidemics. Data for this review were obtained from literature published between 1967 and 2016 in key medical databases, the official websites of various governmental organisations, international public health agencies, and regulatory bodies. Despite major developments in the field of EVD, there has been little progress in its specific therapy or prevention. Historically, individuals who recovered from EVD acted as a source of fresh frozen plasma (containing IgG) that has been used to treat other acutely ill patients, however this therapeutic modality has limitations due to the risk of transmission of blood-borne infections. With the use of advanced and efficient purification methods the incidence of unwanted side effects following immune serum therapy has currently been greatly reduced. Creation of a safe plasma pool that covers immunoglobulins against all strains of EVD is now a research priority. Recommendations on how future EVD outbreaks can be better managed have been discussed.

Cannabis use in patients 3 months after ceasing nabiximols for the treatment of cannabis dependence: Results from a placebo-controlled randomised trial

INTRODUCTION AND AIMS

Previous studies suggest cannabinoid agonist treatment is effective in reducing cannabis use in dependent treatment seekers, however few studies have reported on post-treatment outcomes. We examine cannabis use outcomes 12 weeks after cessation of treatment from a randomised placebo-controlled trial of nabiximols for the treatment of cannabis dependence.

METHOD

128 participants received either nabiximols (n = 61) or placebo (n = 67) for 12 weeks, in combination with psychosocial interventions. Self-reported number of days of cannabis use in the previous 28 days was measured at baseline, 4, 8, and 12 weeks (end of treatment) and again at 24 weeks (3 months after treatment ceased). Urinalysis was used to confirm self-report data at Week 24 interview.

RESULTS

A factorial mixed-effects model for repeated measures regression revealed that the nabiximols group used cannabis on 6.8 fewer days in the previous 28 days at week 12 (end of treatment) than the placebo group (p = 0.002, CI: 2.1,11.4), and 6.7 fewer days in the previous 28 days at the week-24 follow-up than the placebo group (p = 0.006, CI: 1.4,12.1). A significantly higher proportion of the nabiximols group (14/61; 23 %) than the placebo group (6/67; 9%) reported abstinence from cannabis in the previous 28 days at the week-24 research interview OR=3.0, CI: 1.1, 9.1; p=0.035, NNT=8, CI: 4, 71).

DISCUSSIONS AND CONCLUSIONS

The benefits of treatment incorporating nabiximols with psychosocial interventions in reducing cannabis use appears to persist for up to 3 months after the cessation of treatment. A stepped care model of treatment is proposed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12616000103460) https://www.anzctr.org.au.

Hepatitis C virus testing, liver disease assessment and treatment uptake among people who inject drugs pre- and post-universal access to direct-acting antiviral treatment in Australia: The LiveRLife study

Gaps in hepatitis C virus (HCV) testing, diagnosis, liver disease assessment and treatment uptake among people who inject drugs (PWID) persist. We aimed to describe the cascade of HCV care among PWID in Australia, prior to and following unrestricted access to direct-acting antiviral (DAA) treatment. Participants enrolled in an observational cohort study between 2014 and 2018 provided fingerstick whole-blood samples for dried blood spot, Xpert HCV Viral Load and venepuncture samples. Participants underwent transient elastography and clinical assessment by a nurse or general practitioner. Among 839 participants (mean age 43 years), 66% were male (n = 550), 64% (n = 537) injected drugs in the previous month, and 67% (n = 560) reported currently receiving opioid substitution therapy. Overall, 45% (n = 380) had detectable HCV RNA, of whom 23% (n = 86) received HCV treatment within 12 months of enrolment. HCV treatment uptake increased from 2% in the pre-DAA era to 38% in the DAA era. Significant liver fibrosis (F2-F4) was more common in participants with HCV infection (38%) than those without (19%). Age 50 years or older (aOR, 2.88; 95% CI, 1.18-7.04) and attending a clinical follow-up with nurse (aOR, 3.19; 95% CI, 1.61-6.32) or physician (aOR, 11.83; 95% CI, 4.89-28.59) were associated with HCV treatment uptake. Recent injection drug use and unstable housing were not associated with HCV treatment uptake. HCV treatment uptake among PWID has increased markedly in the DAA era. Evaluation of innovative and simplified models of care is required to further enhance treatment uptake.

Designing, implementing and evaluating the overdose response with take-home naloxone model of care: An evaluation of client outcomes and perspectives

INTRODUCTION AND DESIGNS

Take-home naloxone (THN) interventions are an effective response to preventing overdose deaths, however uptake across Australia remains limited. This project designed, implemented and evaluated a model of care targeting opioid users attending alcohol and other drug (AOD) treatment, needle and syringe programs (NSP) and related health services targeting people who inject drugs.

DESIGN AND METHODS

Service providers, consumers and regulators collaboratively designed a THN brief intervention (ORTHN, Overdose Response with Take-Home Naloxone) involving client education and supply of naloxone in pre-filled syringes, delivered by nursing, allied health and NSP workers. ORTHN interventions were implemented in over 15 services across New South Wales, Australia. The evaluation included client knowledge, attitudes, substance use and overdose experiences immediately before and 3 months after ORTHN intervention in a subsample of participants.

RESULTS

Six hundred and sixteen interventions were delivered, with 145 participants recruited to the research subsample, of whom 95 completed the three-month follow up. Overdose-related attitudes amongst participants improved following ORTHN, with no evidence of increased substance use or failure to implement other 'first responses' (e.g. calling an ambulance). Nine participants (10%) reversed an overdose using THN in the follow-up period. Participants identified a willingness to access THN from a range of services. While a minority (16%) indicated they were unwilling to pay for THN, the median price that participants were willing to pay was $AUD20 (IQR $10.40).

DISCUSSION AND CONCLUSIONS

The ORTHN model of care for THN appears an effective way to disseminate THN to people who use opioids attending AOD, NSP and related health-care settings.

Nabiximols for the Treatment of Cannabis Dependence: A Randomized Clinical Trial

IMPORTANCE

There are no effective medications for treating dependence on cannabis.

OBJECTIVE

To examine the safety and efficacy of nabiximols in the treatment of patients with cannabis dependence.

DESIGN, SETTING, AND PARTICIPANTS

This parallel double-blind randomized clinical trial comparing nabiximols with placebo in a 12-week, multisite outpatient study recruited participants from February 3, 2016, to June 14, 2017, at 4 outpatient specialist alcohol and drug treatment services in New South Wales, Australia. Participants had cannabis dependence (as defined by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) and were seeking treatment, were nonresponsive to prior treatment attempts, were 18 to 64 years of age, had no other substance use disorder, had no severe medical or psychiatric conditions, were not pregnant, were not mandated by a court to undergo treatment, and provided informed consent. Results for primary efficacy measures and all secondary outcomes were obtained using a modified intention-to-treat data set.

INTERVENTIONS

Participants received 12-week treatment involving weekly clinical reviews, structured counseling, and flexible medication doses-up to 32 sprays daily (tetrahydrocannabinol, 86.4 mg, and cannabidiol, 80 mg), dispensed weekly.

MAIN OUTCOMES AND MEASURES

Primary outcome was self-reported number of days using illicit cannabis during the 12-week period. Other outcomes included alternate cannabis use parameters (periods of abstinence, withdrawal, cravings, and problems), safety parameters (adverse events and aberrant medication use), health status, other substance use, and treatment retention.

RESULTS

A total of 128 participants (30 women and 98 men; mean [SD] age, 35.0 [10.9] years) were randomized and received at least 1 dose of study medication. Participants had used a mean (SD) of 2.3 (2.1) g of cannabis on a mean (SD) of 25.7 (4.5) days in the past 28 days. Treatment retention was comparable for the 2 groups (placebo, 30 of 67 participants [44.8%]; nabiximols, 30 of 61 participants [49.2%]), and both groups used similar mean (SD) doses (placebo, 18.5 [9.5] sprays daily; nabiximols, 17.6 [9.5] sprays daily, equivalent to a mean [SD] of 47.5 [25.7] mg of tetrahydrocannabinol and 44.0 [23.8] mg of cannabidiol). For the primary end point, the placebo group reported significantly more days using cannabis during the 12 weeks (mean [SD], 53.1 [33.0] days) than the nabiximols group (mean [SD], 35.0 [32.4] days; estimated difference, 18.6 days; 95% CI, 3.5-33.7 days; P = .02). Both groups showed comparable improvements in health status, with no substantial changes in other substance use. Medication was well tolerated with few adverse events.

CONCLUSIONS AND RELEVANCE

This study demonstrates that cannabinoid agonist treatment, in this case using nabiximols, in combination with psychosocial interventions is a safe approach for reducing cannabis use among individuals with cannabis dependence who are seeking treatment.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12616000103460.

Update on global epidemiology of viral hepatitis and preventive strategies

Viral hepatitis is one of the major public health concerns around the world but until recently it has drawn little attention or funding from global health policymakers. Every year 1.4 million people die from viral hepatitis-related cirrhosis and liver cancer. However, the majority of the infected population are unaware of their condition. This population have significant obstacles to overcome such as lack of awareness, vulnerability, increased migration, disease stigma, discrimination, as well as poor health resources, conflict in policy development and program implementation. Despite implementing infection control measures over the last few decades eradication or significant disease reduction remains elusive. This study aims to present the current global prevalence status and examines potential elimination strategies. The information for this research were obtained through a systematic review, published scientific literatures, the official websites of various government organisations, international public health organisations and internationally recognised regulatory bodies over a period of 40 years between 1978 and 2018.

Fournier's gangrene in a five year old boy - beware of the child post varicella infection

Scrotal pain and swelling are common presentations in children and are usually secondary to torsion of the testis, hydatid of Morgagni or epididymo-orchitis. Fournier's gangrene is a rare, but life-threatening disease, that can present in a similar fashion. We present a rare case of Fournier's gangrene in a 5-year-old boy associated with a preceding varicella rash.

Ion transport blockers inhibit human rhinovirus 2 release

Picornavirus replication causes leakage of cytoplasmic K+ and an influx of Na+ and Ca2+. In this study, we have explored the possibility that a blockade of Ca2+ and Na+ influx would reduce rhinovirus production and/or release. The Ca2+-channel blockers, verapamil and diltiazem, as well as the blocker of Na+/H+ exchange and the epithelial Na+ channel, EIPA, inhibited both virus production and release. The effect on virus release was more pronounced than the effect on production, thus raising the possibility that rhinovirus release may serve as a target for antiviral agents. Unexpectedly, our results also showed that the antiviral activity of the Ca2+-channel blockers was not due to the block of Ca2+ influx. Similarly, the antiviral activity of EIPA appeared to be unrelated to the blockade of cellular Na+/H+ exchanger or the epithelial Na+ channel. Potential alternative mechanisms of the antiviral activity of these compounds are discussed.

Revised definition of pre-eclampsia

Different measures of raised blood pressure were analysed in 16,211 singleton pregnancies to determine the most effective way of identifying pre-eclampsia. Increments from baseline in the first half of pregnancy were considered as well as absolute levels. A combination of a high maximum diastolic pressure with a large increase from baseline was better for identifying a group with pre-eclamptic features than either measurement on its own. A first diastolic pressure below 90 mm Hg, a subsequent increase of at least 25 mm Hg, and a maximum reading of at least 90 mm Hg gave appropriate criteria. These were applied to a second set of 15,624 singleton pregnancies and successfully identified a group with pre-eclamptic features. Fewer women were identified as pre-eclamptic than with criteria modified from an existing definition widely used in Britain. The women excluded by the new criteria had the features of mild chronic hypertension rather than pre-eclampsia. The new definition is simple to use but like all other definitions of pre-eclampsia cannot be precise.

CMHC's: relationships with academia and the state

We have surveyed all community mental health centers (CMHC's), state departments of mental health, and university departments of psychiatry in the country to ascertain the status of their relationships with one another. The response rate to a one page questionnaire was 33%. An overwhelming percentage, 88%, of CMHC's have relationships with state hospitals and/or academia. Most often they consist of a service relationship. The control for such relationships is most often shared or there is no one controlling organization. The benefits of such relationships include improved communication, improved access to state hospitals, and improved quality of inpatient and outpatient care. CMHC's who responded to our survey did not think that relationships with the state or academia resulted in improved recruitment of psychiatrists and improved residency training--but state and academic respondents did. All, however, agreed that research, long-term care, and recruitment of other staff are minimally improved by collaborative relationships.

Effect of tone-inhibiting casts and orthoses on gait. A case report

In the adult case presented, inhibitory casting proved successful in decreasing the positive support reaction. When casting was discontinued, the positive reaction returned. To provide a long-term solution for this problem, a polypropylene tone-inhibiting AFO was fabricated. It incorporated the same principles as the casts. The success achieved with casting was rapidly regained and then surpassed with the use of the tone-inhibiting AFO. Natural recovery might be cited by some as the cause for improvement in the patient presented. However, the loss of improvement during the interval between the removal of the inhibitory casts and the initiation of the use of the tone-inhibiting AFO demonstrates that the casting and the position provided by the casts had a positive effect on our patient. This notion is further supported by the fact that our patient still required use of the tone-inhibiting AFO as late as March 1980. We have no explanation for the rapid improvement following the cranioplasty. Suggestions for further research would include a similar study with a larger number of subjects and the use of cinematography and kinesiological EMG during walking with and without tone-inhibiting casts and orthoses to determine the effect of the devices on spastic muscle groups and gait patterns.

Serum and milk alkaline phosphatase in human lactation

Serum and milk alkaline phosphatase (AP) values are reported for the first 16 weeks of lactation. Serum levels at all stages are elevates above normal-pregnant controls. Sequential milk AP values are reported for the first time. Heat inactivation and phenylalanine inhibition studies would suggest that serum AP in lactation is composed of bone and liver isoenzymes, but it shows an increase in the rate at which enzymatic activity is lost when frozen, indicating that lactation serum AP is largely a different isoenzyme. Electrophoresis demonstrates several AP "slow" bands of unknown origin in lactation serum.