High-risk behaviors for HIV: a comparison between crack-abusing and opioid-abusing African-American women

High rates of unprotected sexual behaviors and the exchange of sex for crack have been reported among female crack cocaine users. This subpopulation of drug users is at significant risk for contracting and transmitting HIV and AIDS. To date, there has been no research comparing crack- and opioid-abusing women, particularly regarding their involvement in high-risk behaviors and other key background indicators for different subgroups of drug-abusing women. Sixty-one crack-abusing African-American women who recently entered an intensive outpatient treatment program were compared to 64 matched women whose primary drug of abuse was heroin. The opioid subgroup represented both those who were involved in methadone maintenance and those who were out of treatment. Higher rates of high-risk sexual behaviors were reported by the crack subgroup, including prostitution, number of sexual partners, and infrequency of condom use. As expected, i.v. drug use and high-risk behaviors associated with needle use were much higher among the opioid subgroup. Other significant differences were found between the two groups across key indicators. Individuals in the crack subgroup were younger, cared for more children, were less employable, were less likely to be married, and had more extensive lifetime substance abuse. Quantitative and qualitative background and clinical data are also presented. The nature of crack versus heroin abuse is also discussed, particularly in relation to high-risk sexual behaviors. Finally, the impact of the findings on developing appropriate treatment interventions for both groups is addressed.

Ages of onset of psychiatric disorders in a community population of older adolescents

OBJECTIVE

Ages of onset of psychiatric disorders, as well as the link between early onset and later psychosocial functioning, were examined in a community population of older adolescents.

METHOD

Subjects were 386 adolescents who were participants in an ongoing 14-year longitudinal study. At age 18, lifetime diagnoses and ages of onset of major depression, phobias, post-traumatic stress disorder, and substance disorders were assessed using the NIMH Diagnostic Interview Schedule, Revised Version. Behavioral, emotional, and academic functioning in later adolescence were evaluated through self-report measures and school records.

RESULTS

Almost one fourth of the adolescents met criteria for at least one disorder by age 14. Simple phobias emerged earliest (by early childhood), whereas for major depression and substance disorders the peak risk periods for onset were midadolescence. The early onset (by age 14) of disorders was associated with continued impairments in behavioral and emotional functioning in late adolescence (at age 18). Furthermore, the early onset of disorders, compared to later onset (ages 15 through 18), increased the risk for additional co-occurring disorders.

CONCLUSIONS

The striking levels of early psychopathology and associated long-term deficits in functioning found in this community population underscore the need for programs of early intervention.

Synthesis of novel inhibitors of the HIV-1 protease: difunctional enols of simple N-protected amino acids

A series of enol HIV-1 protease inhibitors which show competitive inhibition and the structure-activity relationship study which led to the design of these compounds are reported. By systematically modifying simple amino acids, Boc-Phe enol and Boc-Tyr enol derivatives yield nanomolar Kiapp values (Kiapp = 0.485 microM and Kiapp = 0.425 microM, respectively). These enols are of low molecular weight (< 500 g/mol) and of non-peptidic nature. The enols are synthesized in a one step chemical synthesis and modifications to increase their potency could easily be performed. Boc-Phe enol and Boc-Tyr enol showed low inhibitory effect on pepsin, Kiapps of 23 and 149 microM, respectively, and Boc-Phe enol showed a Kiapp of 20 microM for cathepsin D. Neither of these two compounds inhibited renin (< 10% inhibition at 200 microM).

Radiation tolerance of the transplanted liver. A histopathologic study in three cases

Three patients with multifocal recurrence of hepatocellular carcinoma following liver transplantation received palliative irradiation. Hyperfractionated irradiation (150 cGy/fraction b.i.d.) was delivered in two cases to the entire liver using parallel opposed oblique portals to a total dose of 30 Gy. Conventional irradiation (180 cGy/fraction) totaling 45 Gy was administered to the liver hilus with concomitant infusional 5-fluorouracil chemotherapy in the third case. Clinicopathologic correlations were performed. At autopsy all patients had massive tumor burden within the liver. Veno-occlusive changes were observed in two patients 1 and 2 months following completion of conventional and hyperfractionated irradiation, respectively. Liver transplantation in these two patients had been performed 18 and 16 months prior to palliative hepatic irradiation. In the third patient, no veno-occlusive changes were pathologically observed at autopsy 1 month after completing hyperfractionated radiation, which was delivered 6 months following liver transplantation. No significant differences in prior immunosuppressive therapy were identified among patients. Veno-occlusive changes are not spared by hyperfractionated radiation. Transplanted livers exhibit responses to radiation similar to those normally observed.

Short versus longer term effectiveness of an outreach program for the homeless mentally ill

Presents 12-month follow-up results from an outreach/linkage intervention with persons who are homeless and mentally ill, contrasting these with results obtained at 4 months. Both sets reflect the success of the program in placing individuals in independent housing. However, longer term data provide useful information regarding client movement patterns and increased tenure in nonhomeless living arrangements beyond the termination of specialized services. Analyses of 12-month residential outcomes identified four variables as significant predictors: recruitment source, project service duration, CMH service duration, and client age. In contrast to 4-month predictors, variables reflecting baseline client functioning were no longer significantly related to outcome, suggesting that the positive effects of the intervention may take longer to achieve with some clients. Discussion focuses on the implications of these effectiveness results for future research designs and measures as well as the utility and limitations of preexperimental approaches for evaluating innovative service models when implementation and efficacy experiences are lacking.

The effects of insurance benefits coverage on functional and psychosocial outcomes after spinal cord injury

This retrospective study examined the effects of type of payor (ie, catastrophic, Medicaid, and private) and extent of benefits and independent living (IL) resources received on functional and psychosocial outcomes after spinal cord injury (SCI). One hundred seventy SCI persons with dates of injury from 1985 to 1990 and who were on average 4 years after their initial discharge from rehabilitation participated in the study. Benefits and resources received from discharge to 2 years post-injury in housing, transportation, personal care assistance (PCA), and equipment were assessed. Outcome variables included measures of psychological distress, self-esteem, and participation in physical and work/school activities. Extent of benefits received after SCI was found to be both a function of source of payor and of subject's neurological classification. While an effect of total benefits received could not be detected on SCI subjects post-discharge physical activity, and benefits paid by self only were associated with physical activity. Transportation benefits received and type of payor were positively associated with work/school outcomes. Younger subjects, sponsored by private payors, and with incomplete injuries were more likely to be working or going to school after SCI. Benefits and payor were also associated with psychological distress. Privately sponsored subjects were less distressed, whereas those sponsored by Medicaid were most distressed. Extent of benefits received was found to be inversely associated with distress and self-esteem. Persons with lower self-esteem received more postdischarge benefits, whereas those who paid for their own benefits and those who received communication equipment benefits paid by insurance, reported higher self-esteem. Implications for possible policy changes based on these results are discussed.

Increased thromboxane mediates the adverse renal effects of interleukin-2 in rats

The capillary leak syndrome with decreased GFR and renal water and sodium retention after recombinant interleukin-2 (IL-2) administration may arise from endothelial activation via an increase in prostaglandin synthesis. This study was undertaken to better define the role of the prostaglandin system in the renal and metabolic effects of IL-2 administration in rats. The chronic administration of IL-2 (100,000 U/kg, thrice daily, ip) resulted in a significant increase in body weight, a decrease in GFR and in the urinary excretion of sodium and potassium, and an increase in the urinary excretion of thromboxane (TXB2). After combined IL-2 and low-dose indomethacin (1.7 mg/kg per day po), a significant decrease in body weight with normalization of GFR, of the urinary excretion of Na, and of urinary TXB2 was noted in animals receiving combined therapy as compared with those receiving IL-2 alone. In contrast, high-dose indomethacin administration (33.3 mg/kg po for the last 3 days of the study) was associated with a further decrease in GFR, enhancement of the sodium and potassium retention, and suppression of prostaglandin E2 excretion. The administration of the thromboxane receptor antagonist SQ 29548 in IL-2-treated rats led to a reversal of the fall in GFR induced by the lymphokine without significant changes in urinary sodium excretion. These results support the hypothesis that thromboxane is an important mediator of the renal and systemic effects of IL-2. These effects are reversed at least partly by low-dose indomethacin, which selectively suppresses thromboxane A2 (TXA2) synthesis, or by TXA2 receptor antagonism.

Demonstration by two-color flow cytometry that tyrosine kinase activity is required for down-modulation of the oncogenic neu receptor

Expression of rat oncogenic neu receptor, p185T-neu (a growth factor receptor with constitutive tyrosine kinase activity), causes cells to become transformed. Treatment with anti-neu receptor monoclonal antibodies reverts the transformed phenotype by down-modulation of p185T-neu. Monoclonal antibody treatment of cells expressing normal neu receptor, p185C-neu (which lacks constitutive tyrosine kinase activity), does not result in down-modulation of p185C-neu. To understand further the role the biochemical activity of p185T-neu plays in transformation and endocytosis, we created a series of mutations in p185T-neu. We found that fibroblasts expressing the tyrosine kinase-defective mutants cannot form foci in culture, colonies in soft agar, or tumors in immunocompromised mice. To follow the antibody-induced endocytosis of neu receptors expressed in these transfectants, we developed a novel two-color flow cytometric assay and confirmed receptor localization by electron microscopy. Cells were treated with mAb7.16.4 over time. After 4 hr of antibody treatment, less than 50% of full-length p185T-neu and of mutant T691 remained on the cell surface, whereas internal expression of the neu receptors within these cells initially increased and then decreased to the original internal receptor level. In contrast, the level of kinase-deficient mutated neu receptors remaining on the cell surface initially decreased by 35%, but, after 4 hr of antibody treatment, the cell surface expression level returned to approximately the original level. Concurrently, fluctuations in expression levels were seen internally over time as well. These cell lines were also treated with gold-conjugated mAb7.16.4. Using electron microscopy, we consistently found the gold particles within multivesicular bodies of cell lines expressing full-length or mutated neu receptor. These data strongly suggest that the fate of the neu receptor, once internalized, is directed by its tyrosine kinase activity. When the kinase activity of the neu receptor is disrupted, the receptor is internalized but recycled to the cell surface, whereas neu receptors which have constitutive kinase activity are internalized and presumably degraded when engaged with anti-neu receptor mAb. Understanding the regulation of receptor endocytosis, degradation, and recycling will contribute to the development of novel therapeutic protocols to combat human malignancies, particularly those associated with the overexpression of the human homologue of the neu receptor, c-erbB2.

Damage awards and jurors' responsibility ascriptions in medical versus automobile negligence cases

Many critics of the tort system have accused juries of assessing larger awards against defendants perceived to have the ability to pay. Juries are said to be particularly prone to go after the 'deep pockets' of doctors in medical malpractice cases as compared to defendants found negligent in automobile accidents. This hypothesis was put to a test in an experiment that manipulated cause of the injury (medical malpractice versus negligent driving) and degree of possible contributing responsibility by the plaintiff (mandatory versus elective surgery and plaintiff as another driver or as a passenger). Responsibility ascriptions to the plaintiff differed across conditions, but jurors did not differentially award pain and suffering damages across conditions.

Prevention of soman-induced cognitive deficits by pretreatment with human butyrylcholinesterase in rats

This study examined the ability of pretreatment with human serum butyrylcholinesterase (HuBChE) to prevent soman-induced cognitive impairments. Behavioral testing was carried out using the Morris water maze task evaluating learning, memory, and reversal learning processes. Pretreatment with HuBChE significantly prevented the memory and reversal learning impairments induced by soman. A small deficiency in performance was observed only during part of the learning period in HuBChE-treated rats after administration of soman. Results support the contention that pretreatment alone with HuBChE is sufficient to increase survival and to prevent impairment in cognitive functioning following exposure to soman.

Transoesophageal echocardiography and the intraoperative diagnosis of left atrial invasion by carcinoid tumour

A 41-yr-old woman with pulmonary carcinoid tumour presented for thoracotomy and lung resection. However, intraoperative transoesophageal echocardiography (TEE) revealed that the tumour had invaded the left atrium, and the planned resection was aborted to allow resection under cardiopulmonary bypass at a later date. Although the incidence of cardiac involvement by lung cancer at the time of pulmonary resection is unknown, transoesophageal echocardiography can be useful in identifying the extension of hilar lung tumours. This should preferentially be done preoperatively, but can be done intraoperatively as described in this case report.

Human butyrylcholinesterase as a general prophylactic antidote for nerve agent toxicity. In vitro and in vivo quantitative characterization

Butyrylcholinesterase purified from human plasma (HuBChE) was evaluated both in vitro and in vivo in mice and rats as a single prophylactic antidote against the lethal effects of highly toxic organophosphates (OP). The variation among the bimolecular rate constants for the inhibition of HuBChE by tabun, VX, sarin, and soman was 10-fold (0.47 to 5.12 x 10(7) M-1 min-1; pH 8.0, 26 degrees). The half-life of HuBChE in blood after its i.v. administration in mice and rats was 21 and 46 hr, respectively. The peak blood-enzyme level was obtained in both species approximately 9-13 hr following i.m. injection of HuBChE, and the fraction of the enzyme activity absorbed into the blood was 0.9 and 0.54 for rats and mice, respectively. The stoichiometry of the in vivo sequestration of the anti-cholinesterase toxicants was consistent with the HuBChE/OP ratio of the molar concentration required to inhibit 100% enzyme activity in vitro. Linear correlation was demonstrated between the blood level of HuBChE and the extent of protection conferred against the toxicity of nerve agents. Pretreatment with HuBChE alone was sufficient not only to increase survivability following exposure to multiple median lethal doses of a wide range of potent OPs, but also to alleviate manifestation of toxic symptoms in mice and rats without the need for additional post-exposure therapy. It appeared that in order to confer protection against lethality nerve agents had to be scavenged to a level below their median lethal dose LD50 within less than one blood circulation time. Since the high rate of sequestration of nerve agents by HuBChE is expected to underlie the activity of the scavenger in other species as well, a reliable extrapolation of its efficacy from experimental animals to humans can be made.

Preparing for terror

Terrorists enjoy their exposure in the international press. Their acts and treats of violence are heralded in headlines and broadcast throughout the world. They purposely inflict damage in public places where there are large numbers of victims, with the potential for a great deal of destruction and debris. They intend to inflict economic loss, instill fear and disrupt everyday life, while at the same time believing their need to maim and kill is justified. Is it no wonder that the World Trade Center was a highly prized target? You must remember that terrorism involves the perpetrator's willful, calculated choice to use innocent victims as targets, and that the terrorist's acts are deliberate, systematic murders to inspire fear for political or criminal ends. As Brian Jenkins stated back in 1983, "terrorism is never a short-term event...you never really get over it...and its effects can't be buried or forgotten." Thus, our responsibility, as EMS providers, is to recognize the threat and refuse to be lulled into a sense of complacency. The United States is at risk, and our greatest threat may even come from our own ranks: political crusaders, activists, hate groups, drug merchants and gangs. The criminals, zealots, fanatics and extremists of the world will continue to believe their crusades and turf battles can be won through terrorist acts. It's up to us to respond effectively to the aftermath.

Lack of exposure to HTLV1 among Ethiopian immigrants of operation Solomon (1991) arriving to the Jerusalem area

HTLV1 antibodies were tested in a group of 740 Ethiopian immigrants who arrived in Israel in Operation Solomon, 1991. HTLV1 antibodies were not found in a single individual. This survey and previous ones conducted on 314 immigrants of the 1984-85 Operation Moses suggest that HTLV1 infection is not present among Ethiopian immigrants residing in Israel.

Identification of tRNAs incorporated into wild-type and mutant human immunodeficiency virus type 1

We have identified the tRNAs which are incorporated into both wild-type human immunodeficiency virus type 1 strain IIIB (HIV-1IIIB) produced in COS-7 cells transfected with HIV-1 proviral DNA and mutant, noninfectious HIV-1Lai particles produced in a genetically engineered Vero cell line. The mutant proviral DNA contains nucleotides 678 to 8944; i.e., both long terminal repeats and the primer binding site are absent. As analyzed by two-dimensional polyacrylamide gel electrophoresis, both mutant and wild-type HIV-1 contain four major-abundance tRNA species, which include tRNA(1,2Lys), tRNA(3Lys) (the putative primer for HIV-1 reverse transcriptase) and tRNA(Ile). Identification was accomplished by comparing the electrophoretic mobilities and RNase T1 digests with those of tRNA(3Lys) and tRNA(1,2Lys) purified from human placenta and comparing the partial nucleotide sequence at the 3' end of each viral tRNA species with published tRNA sequences. Thus, the absence of the primer binding site in the mutant virus does not affect tRNA(Lys) incorporation into HIV-1. However, only the wild-type virus contains tRNA(3Lys) tightly associated with the viral RNA genome. The identification of the tightly associated tRNA as tRNA(3Lys) is based upon an electrophoretic mobility identical to that of tRNA(3Lys) and the ability of this RNA to hybridize with a tRNA(3Lys)-specific DNA probe. In addition to the four wild-type tRNA species, the mutant HIV-1-like particle contains two tRNA(His) species and three tRNA-sized species that we have been unable to identify. Their absence in wild-type virus makes it unlikely that they are required for viral infectivity.

Who will practise emergency medicine? Survey of family medicine graduates

A survey of recent family medicine graduates showed that two thirds were doing no emergency work. Those who had originally planned to practise emergency medicine were more likely to be doing it than those who had not. More women than men dropped their plans to do emergency work. Two thirds of those who had dropped their plans thought their training had influenced the decision.

Intrathecal morphine during thoracotomy, Part II: Effect on postoperative meperidine requirements and pulmonary function tests

The ability of intrathecal morphine (ITM) to reduce post-thoracotomy pain and meperidine requirements was investigated. Thirty adult patients scheduled for thoracic surgery were studied. Following induction with thiamylal sodium and succinylcholine, anesthesia was maintained with 100 micrograms of fentanyl, vecuronium, and enflurane. Prior to skin incision, 16 patients received intrathecal morphine, 12 micrograms/kg, injected at the L3-4 or L4-5 level. The other 14 patients were controls. Postoperatively, patients were evaluated for pain scores and the total doses of meperidine required over 24 hours. The patients in the ITM group required significantly less meperidine compared to the control group (59 +/- 68 v 167 +/- 97 mg, respectively) and had lower pain scores (1.4 +/- 1.1 v 2.4 +/- 0.9 mg, respectively). There were no serious side effects attributable to ITM. It is concluded that ITM is an effective adjunctive treatment for control of post-thoracotomy pain.