Outpatient benzodiazepine detoxification procedure for methadone patients

Benzodiazepines are used by a substantial minority of opioid addicts on methadone maintenance. Alprazolam, now the most widely prescribed benzodiazepine in the United States, appears to have supplanted diazepam as the benzodiazepine drug of choice in this population. Its greater addiction liability, shorter half-life, and more intense withdrawal symptoms make addiction to alprazolam more likely and its management in methadone patients more complicated. This article describes a slow outpatient tapered reduction procedure that was utilized to detoxify benzodiazepine dependent methadone patients seen over a two-year period. The reduction procedure was offered to 22 opioid addicts on methadone maintenance who were regularly ingesting low to moderate amounts of benzodiazepines, primarily alprazolam. Of the 22 patients, 4 patients refused outpatient detoxification, and 18 were started on a reduction procedure. Twelve patients completed the detoxification procedure which averaged 7.8 weeks. Comparisons are made between completers and non-completers and essential design features of the procedure are discussed.

Rehabilitation for adults with severe mental illness and substance use disorders. A clinical trial

Faced with many patients with comorbid severe mental illness and substance use disorders, a university-affiliated, inner-city community mental health center and a psychosocial rehabilitation center initiated this clinical trial assessing a program to care for these patients. Fifty-four patients, age 18 to 40, with either schizophrenia or major affective disorder and a substance use disorder were randomly assigned to usual community mental health center and rehabilitation services with or without an innovative group and intensive case management program. One-year follow-ups detected no significant advantages on patient outcomes for adding the innovative program to usual services. Failure to engage patients in the experimental program posed a major and enduring barrier to treatment, despite intensive case management. Future efforts must give greater consideration to effective engagement techniques and patients' readiness for active treatment.

Hospital-based professional assistance committees: literature review and guidelines

This paper presents a review of the current literature on hospital professional assistance committees, a discussion of key issues, and a set of guidelines for the design and operation of these committees. The employee assistance program is suggested as a resource to these committees.

Animal models for protecting ischemic myocardium: results of the NHLBI Cooperative Study. Comparison of unconscious and conscious dog models

The Animal Models for Protecting Ischemic Myocardium Study was undertaken for the purpose of developing reproducible animal models that could be used to assess interventions designed to limit infarct size. This paper describes the results obtained in an unconscious dog model and in a conscious dog model, developed in three participating laboratories. The unconscious dog model, involving reperfusion after 3 hours of ischemia in open-chest dogs, was intended to determine whether therapy followed by early reperfusion would limit infarct size more than reperfusion alone. The conscious dog model used chronically instrumented dogs and permanent coronary occlusion to better mimic myocardial infarction in man. In both models, the proximal circumflex artery was occluded, and the primary experimental endpoint was infarct size, as measured by histological techniques 3 days after the initial occlusion. Infarct size was analyzed in relation to baseline variables including the anatomic area at risk, collateral blood flow to the subepicardial zone of ischemia and hemodynamic determinants of myocardial metabolic demand. Most of the variation in infarct size in control dogs could be related to variation in the area at risk, collateral blood flow, and rate pressure product. Using multivariate analysis and groups of 15 dogs, an intervention that limited infarct size by 10-13% of the area at risk would have been detected 50% of the time. Larger treatment effects would be detected more readily, and smaller effects often would be missed, unless group sizes were larger. Two drugs, verapamil and ibuprofen, were evaluated in both models, with experimental group sizes averaging 13 and 20 dogs, in the unconscious and conscious models, respectively. Three of 15 verapamil-treated dogs in the unconscious model study had much smaller infarcts than expected from baseline parameters. With these exceptions, neither drug limited infarct size in either model.

Cervical cerclage. A review of 74 cases

The records of seventy-four patients who had had cervical cerclage procedures were surveyed. Without suture placement, these patients would have had a fetal salvage rate of 23%. The Shirodkar method was performed in 67 cases and the McDonald in 7. Spontaneous abortions occurred in ten women (13.5%). Four pregnancies terminated between the 20th and 26th week of gestation; two of these losses were due to chorioamnionitis and two to immature labor. No congenital anomalies were noted. In the remaining 60 patients, 6 pregnancies terminated between the 28th and the 36th week of gestation, and 54 pregnancies were carried beyond the 36th week; all of these infants survived. The salvage rate after the cerclage procedure was 81.8%. The average length of labor in the patients who delivered vaginally was 9 hours, 18 minutes. The incidence of cervical lacerations was 3%. Eight cesarean sections were performed (13.3%) for various reasons.

Endodermal sinus tumor in pregnancy: report of a case and review of the literature

The endodermal sinus tumor is a rare germ cell tumor characterized by extremely rapid growth and grave prognosis. The case of a 17-year-old black primigravida with a 19-week intrauterine gestation and concurrent endodermal sinus tumor of the ovary is presented. This case is the eighth reported case of this tumor during pregnancy. alpha-Fetoprotein and other oncofetal antigens are postulated as agents of rapid growth of this tumor. It is suggested that immunotherapy with antibodies against alpha-fetoprotein and other oncofetal antigens might change the unfavorable outcome of this tumor.

Gonadal dysgenesis, intra-X chromosome insertion, and possible position effect in an otherwise normal female

A 16-year-old female was referred for cytogenetic evaluation because of primary amenorrhea. Growth, mental development, and physical examination, including secondary sexual characteristics, were normal. Cytogenetic analysis revealed one X chromosome to be consistently more metacentric than the other. Measurements indicted no significant differences between the two X's, but in the abnormal X, the increase in length of the short arm matched the decrease in length of the long arm. Banding studies suggest that region q22 through q24 of the abnormal X is inserted into region p11 of the same chromosome. Endocrine studies were indicative of gonadal dysgenesis. Since no loss of X chromosome material is involved, this patient's gonadal dysgenesis is most likely related to position effect.

'Not Cushing's syndrome'

Cushing's syndrome is characterized by protein wasting secondary to hypergluconeogenesis, which produces thin skin, poor muscle tone, osteoporosis and capillary fragility. These features distinguish patients with true Cushing's syndrome from those who have some of the clinical findings often associated with the syndrome, such as obesity, hypertension, striae and hirsutism. The dexamethasone suppression test helps identify patients with pseudo-Cushing's syndrome.

Loss of transferase enzyme activity of transfused erythrocytes in galactosemia

Rapid loss of erythrocyte galactose-1-phosphate uridyl transferase in hemolysates from an infant 26 days after transfusion led to investigation of the possiblity of an unstable enzyme or other variant of galactosemia. However, the child was found to have the classic type of galactosemia. The seeming transferase instability was attributable to loss of enzyme activity in hemolysates from blood containg aged, transfused cells, the source of the enzyme. Thus when transfusion is necessary, transferase assay for diagnosis of the enzyme deficiency before transfusion avoids confusion attributable to the enzyme supplied in the transfused cells.