Clinical profile of participants in a brief intervention program for cannabis use disorder

The increasing demand for cannabis dependence treatment has led to the identification of significant gaps in the knowledge of effective interventions. A randomized controlled trial of brief cognitive-behavioral interventions (CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and allocated to either a 6-session CBT program, a single-session brief intervention, or a delayed-treatment control group. This paper demonstrates that individuals with cannabis use disorder will present for a brief intervention program. While they report similar patterns of cannabis use to nontreatment samples, they report a range of serious health and psychosocial consequences. While they appear relatively socially stable, they typically demonstrated severe cannabis dependence and significantly elevated levels of psychological distress, with the most commonly cited reason for cannabis use being stress relief. There were clinically relevant gender differences among the sample. This study provides more evidence of the demand for, and nature of issues relevant to, interventions for cannabis use disorders, and supports the need for further research into how best to assist individuals with these disorders.

Validation of the Hamilton Depression Rating Scale and Montgommery and Asberg Rating Scales in terms of AGECAT depression cases

OBJECTIVE

To validate the Hamilton Depression (17) and Montgommery and Asberg Depression Scales as research instruments in older depressed community residents.

DESIGN

External validation against GMS/AGECAT case level in the recruitment of older community residents for an antidepressant trial.

ANALYSES

Receiver operator curves were generated for each rating scale, using GMS/AGECAT case level in external criterion. The sensitivity, specificity, positive and negative predictive values of both rating instruments were examined in the whole sample and age and gender subgroups. MADRS and HAM-D cut-off scores differentiating GMS/AGECAT cases from subcases were identified.

RESULTS

HAM-D cut-off score of 16 and MADRS score of 21 were identified as differentiating case from sub-case. Diagnostic accuracy of both instruments was good, reflecting good sensitivity and specificity across both genders and sub-age groups.

CONCLUSIONS

Both scales performed well in this population. These scores provide researchers with externally validated and clinically relevant cut-off scores in designing trials in the management of older depressed community residents.

Cannabis use among Australian adolescents: findings of the 1998 National Drug Strategy Household Survey

OBJECTIVE

To describe the prevalence, context and recent trends in cannabis use among Australian adolescents.

METHOD

Data was collected from 1,581 adolescents aged 14-19 years as part of the 1998 National Drug Strategy Household Survey, and comparisons were made with data from 350 adolescents who participated in the 1995 survey.

RESULTS

Among 14-19 year olds, 47.8% have had the opportunity to use cannabis in the past year and 45.2% have used cannabis at least once in their lifetime. Substantial increases have occurred since 1995 in the prevalence of use among young females. While most cannabis use was fairly infrequent, a minority of 14-19 year olds (9.4%) used cannabis at least weekly. Cannabis use was associated with regular tobacco and alcohol use, and other illicit drug use. Regular cannabis users had lower levels of health on the general health and vitality dimensions of the SF-36.

IMPLICATIONS

These results show that cannabis availability and use is common among Australian adolescents, and confirm that there has been an increase in use between 1995 and 1998, although only among young females. Future research is required to understand why this recent increase has occurred, and trends in cannabis uptake and use patterns among this group should be carefully monitored. Interventions may need to be developed and made available to the group of young people who are using cannabis heavily.

Anabolic-androgenic steroid use disorders among a sample of Australian competitive and recreational users

Illicit anabolic-androgenic steroid (AAS) use, for body building and body image purposes, is increasing internationally. This study describes the prevalence and symptoms of AAS use disorders obtained using a semi-structured interview among a mixed-gender sample of 100 current Australian users, that were recruited from a variety of sources. The median age of the sample was 27 years and 94% were male. The full range of DSM IV symptoms of AAS abuse and dependence were reported and over three quarters (78%) of the sample exhibited at least one symptom of abuse or dependence on AAS. A total of 23% of the participants qualified for a diagnosis of AAS dependence using DSM IV criteria and a further 25% met criteria for AAS abuse. There were no gender differences in AAS abuse or dependence diagnoses. The only variable related to an AAS substance use disorder was reporting the experience of AAS-related aggression, which may be a useful clinical indicator of the disorder.

Pretreatment with cationic lipid-mediated transfer of the Na+K+-ATPase pump in a mouse model in vivo augments resolution of high permeability pulmonary oedema

Resolution of pulmonary oedema is mediated by active absorption of liquid across the alveolar epithelium. A key component of this process is the sodium-potassium ATPase (Na+K+-ATPase) enzyme located on the basolateral surface of epithelial cells and up-regulated during oedema resolution. We hypothesised that lung liquid clearance could be further up-regulated by lipid-mediated transfer and expression of exogenous Na+K+-ATPase cDNA. We demonstrate proof of this principle in a model of high permeability pulmonary oedema induced by intraperitoneal injection of thiourea (2.5 mg/kg) in C57/BL6 mice. Pretreatment of mice (24 h before thiourea) by nasal sniffing of cationic liposome (lipid #67)-DNA complexes encoding the alpha and beta subunits of Na+K+-ATPase (160 microg per mouse), significantly (P<0.01) decreased the wet:dry weight ratios measured 2 h after thiourea injection compared with control animals, pretreated with an equivalent dose of an irrelevant gene. Whole lung Na+K+-ATPase activity was significantly (P<0.05) increased in mice pretreated with Na+K+-ATPase cDNA compared both with untreated control animals as well as animals pretreated with the irrelevant gene. Nested RT-PCR on whole lung homogenates confirmed gene transfer by detection of vector-specific mRNA in three of four mice studied 24 h after gene transfer. This demonstration of a significant reduction in pulmonary oedema following in vivo gene transfer raises the possibility of gene therapy as a novel, localised approach for pulmonary oedema in clinical settings such as ARDS and lung transplantation.

One year follow-up of cannabis dependence among long-term users in Sydney, Australia

Eighty one percent of a sample of long-term cannabis users was followed up at 1 year (162/200). Half (51%) were daily smokers, while 20% had substantially decreased or ceased use. More than half received a dependence diagnosis on each of three measures in the last year, with 44% dependent on all three. Remission was much more common than incidence of dependence. Nevertheless, use and dependence patterns were strongly related over time. Longitudinal analyses revealed that quantity of use and severity of dependence at baseline were the primary predictors of those same variables at follow-up. These data suggest that cannabis use and dependence are fairly stable among long-term users.

Safety, tolerability and efficacy of cyclosporine microemulsion in heart transplant recipients: a randomized, multicenter, double-blind comparison with the oil based formulation of cyclosporine--results at six months after transplantation

BACKGROUND

The introduction of cyclosporine has resulted in significant improvement in the survival of cardiac allograft recipients due to decreased mortality from infection and rejection. The original oil-based cyclosporine formulation exhibits variable and unpredictable bioavailability that correlates with an increased incidence of acute and chronic rejection in those patients in whom this is most pronounced. The primary objectives of this prospective, multicenter, randomized, double-blind study in cardiac transplant patients were: to compare the efficacy of cyclosporine microemulsion (CsA-NL) with oil-based cyclosporine (CsA-SM) as measured by cardiac allograft and recipient survival and the incidence and severity of acute rejection episodes; and to assess the safety and tolerability of CsA-NL compared with CsA-SM in this population. This report represents the analysis of results 6 months after transplantation.

METHODS

A total of 380 patients undergoing their first cardiac transplant at 24 centers in the United States, Canada, and Europe were enrolled in this double-blind, randomized trial examining the safety and efficacy of CsA-NL versus CsA-SM. Rejection was diagnosed using endomyocardial biopsy and were graded according to standardized criteria of the International Society of Heart and Lung Transplantation (ISHLT). Clinical parameters were monitored during the study. Survival and freedom from were used for analysis as was Fisher's exact test for comparisons between groups.

RESULTS

At 6 months after transplantation, allograft and patient survival were the same for both groups. The frequency of ISHLT grade 3A or greater episodes in the two groups was identical. Fewer CsA-NL patients (5.9%) required antilymphocyte antibody (ATG or OKT-3) therapy for rejection compared with the CsA-SM-treated patients (14.1%, P=0.01). Females with ISHLT rejection grade > or = 3A treated with CsA-NL had a 46% lower incidence of rejection compared with the CsA-SM-treated group (31.3% vs. 57.6%, P=0.032). Fewer infections were seen in the CsA-NL. With the exception of baseline and 1 week posttransplant creatinines which were higher in the CsA-NL group, the overall creatinine was not significantly different between the two groups.

CONCLUSIONS

This multicenter, randomized study of cardiac transplant recipients documented less severe rejection (in particular those requiring antibody therapy) and a lower incidence of infection in CsA-NL-treated patients. Results from the female subgroup analysis suggest that the improved bioavailability of CsA-NL might reduce the frequency of rejection episodes in female patients. The use of CsA-NL was not associated with an increased risk of adverse events.

Signal-regulated activation of serum response factor is mediated by changes in actin dynamics

Serum response factor (SRF) regulates transcription of many serum-inducible and muscle-specific genes. Using a functional screen, we identified LIM kinase-1 as a potent activator of SRF. We show that SRF activation by LIM kinase-1 is dependent on its ability to regulate actin treadmilling. LIM kinase activity is not essential for SRF activation by serum, but signals depend on alterations in actin dynamics. Studies with actin-binding drugs, the actin-specific C2 toxin, and actin overexpression demonstrate that G-actin level controls SRF. Regulation of actin dynamics is necessary for serum induction of a subset of SRF target genes, including vinculin, cytoskeletal actin, and srf itself, and also suffices for their activation. Actin treadmilling provides a convergence point for both serum- and LIM kinase-1-induced signaling to SRF.

Retention of the BUB3 checkpoint protein on lagging chromosomes

Accurate chromosome segregation at mitosis is ensured both by the intrinsic fidelity of the mitotic machinery and by the operation of checkpoints that monitor chromosome-microtubule attachment. When unattached kinetochores are present, anaphase is delayed and the time available for chromosome-microtubule capture increases. Genes required for this delay first were identified in budding yeast (the MAD and BUB genes), but it is not yet known how the checkpoint senses unattached chromosomes or how it signals cell-cycle arrest. We report the isolation and analysis of a murine homologue of BUB3, a gene whose deletion abolishes mitotic checkpoint function in Saccharomyces cerevisiae. mBub3 belongs to a small gene family that has been highly conserved through evolution. By expressing recombinant proteins in insect cells, we show that mBub3, like yeast Bub3p, binds to Bub1 to form a complex with protein kinase activity. During prophase and prometaphase, preceding kinetochore-microtubule attachment, Bub3 localizes to kinetochores. High levels of mBub3 remain associated with lagging chromosomes but not with correctly aligned chromosomes during metaphase, consistent with a role for Bub3 in sensing microtubule attachment. Intriguingly, the number of lagging chromosomes with high Bub3 staining increases dramatically in cells treated with low (and pharmacologically relevant) concentrations of the chemotherapeutic taxol and the microtubule poison nocodazole.

Exploring male fertility options after spinal cord injury: the role of the nurse clinician

Male sexual function and fertility are important areas that need to be addressed for men undergoing spinal cord injury (SCI) rehabilitation. Rehabilitation nurses need to understand what fertility after SCI involves. Significant advances in the areas of sperm retrieval and advanced reproductive technologies have made biological parenthood for many men with SCI a viable option. This article reviews the various sperm retrieval techniques and advanced reproductive technologies available today. It also describes the unique role of a nurse clinician working in a fertility clinic designed specifically to address the fertility concerns of men and their partners after SCI.

Characteristics of long-term cannabis users in Sydney, Australia

Two hundred long-term cannabis users (58% male) were interviewed on their characteristics and experience of use. Respondents had been regularly using cannabis for an average of 11 years and more than half used daily (56%). The most common route of administration was in a waterpipe, and nearly all (93%) smoked the flowering heads ot the plant. One in 5 (21%) had a cannabis-related conviction. The benefits of use were perceived to be its relaxing, mood-enhancing effects, and its ability to alter consciousness. The most commonly cited negative aspects of use were cost, negative psychological effects and legal status. Polydrug use was common, with alcohol and tobacco almost universally used on a regular basis. More than half the drinkers in the sample were consuming alcohol at hazardous or harmful levels.

Choosing a diagnostic cut-off for cannabis dependence

AIM

While cannabis dependence has been increasingly recognized, there is little research on the measurement issues involved in operationalizing the dependence syndrome for this drug. This paper aimed to investigate the diagnostic utility and appropriate diagnostic cut-offs of three short dependence measures among long-term cannabis users.

SETTING AND PARTICIPANTS

Two hundred long-term, regular cannabis users were recruited and interviewed in Sydney, Australia.

MEASUREMENTS

Receiver Operating Characteristic analyses compared the diagnostic performance of the short University of Michigan CIDI, a measure of ICD-10 dependence and the Severity of Dependence Scale against the "gold standard" of moderate or more severe DSM-III-R cannabis dependence, as diagnosed by the Substance Abuse Module of the CIDI.

FINDINGS

The measures were of equal utility in diagnosing at least moderate DSM-III-R cannabis dependence. While the optimal diagnostic cut-offs for the short University of Michigan CIDI and the ICD-10 dependence measure remained unchanged from those conventionally applied, a more liberal cut-off was optimal for the Severity of Dependence Scale. The amended prevalence of cannabis dependence was 77% using the short University of Michigan CIDI, 72% by the ICD-10 measure and 62% by the Severity of Dependence Scale.

CONCLUSIONS

The three instruments were able to diagnose cannabis dependence at levels substantially better than chance. They were generally robust in terms of the optimal diagnostic cut-off in a population of long-term cannabis users. This paper provides guidelines for choosing optimal cut-offs within different contexts.

Understanding and assessing the motivations of volunteers: a functional approach

The authors applied functionalist theory to the question of the motivations underlying volunteerism, hypothesized 6 functions potentially served by volunteerism, and designed an instrument to assess these functions (Volunteer Functions Inventory; VFI). Exploratory and confirmatory factor analyses on diverse samples yielded factor solutions consistent with functionalist theorizing; each VFI motivation, loaded on a single factor, possessed substantial internal consistency and temporal stability and correlated only modestly with other VFI motivations (Studies 1, 2, and 3). Evidence for predictive validity is provided by a laboratory study in which VFI motivations predicted the persuasive appeal of messages better when message and motivation were matched than mismatched (Study 4), and by field studies in which the extent to which volunteers' experiences matched their motivations predicted satisfaction (Study 5) and future intentions (Study 6). Theoretical and practical implications are discussed.

Understanding and assessing the motivations of volunteers: a functional approach

The authors applied functionalist theory to the question of the motivations underlying volunteerism, hypothesized 6 functions potentially served by volunteerism, and designed an instrument to assess these functions (Volunteer Functions Inventory; VFI). Exploratory and confirmatory factor analyses on diverse samples yielded factor solutions consistent with functionalist theorizing; each VFI motivation, loaded on a single factor, possessed substantial internal consistency and temporal stability and correlated only modestly with other VFI motivations (Studies 1, 2, and 3). Evidence for predictive validity is provided by a laboratory study in which VFI motivations predicted the persuasive appeal of messages better when message and motivation were matched than mismatched (Study 4), and by field studies in which the extent to which volunteers' experiences matched their motivations predicted satisfaction (Study 5) and future intentions (Study 6). Theoretical and practical implications are discussed.

Exploring the nature of the relationship between child sexual abuse and substance use among women

AIMS

This study investigated whether child abuse (CSA) was associated with earlier substance use and greater severity of substance dependence and what aspects of CSA might predict substance abuse.

DESIGN

The study compared (a) drug and alcohol treatment clients with and without a history of CSA and (b) CSA survivors outside drug and alcohol treatment who did or did not have current substance abuse.

SETTINGS

Semi-structured interviews took place at participants' homes, treatment agencies or the research centre.

PARTICIPANTS

Volunteer participants included 100 women recruited from drug and alcohol treatment programmes and 80 CSA survivors recruited through CSA counseling services and medial advertising.

MEASUREMENTS

The results focus on data from the Opiate Treatment Index, Severity of Alcohol Dependence Questionnaire, Substance Dependence Scale, Self-Esteem Inventory and self-reported histories of CSA.

FINDINGS

There were no differences between CSA survivors and other drug and alcohol treatment clients in their severity of dependence. Women with a history of CSA more frequently identified stimulants as their main problem drug and reported an earlier age of first intoxication and earlier use of inhalants. Among abused CSA survivors outside drug and alcohol treatment, women with current substance abuse had typically been abused during adolescence by someone outside the family, whereas those without current substance abuse were typically abused by family members before adolescence.

CONCLUSIONS

The results suggest that adolescence is a crucial time for the influence of CSA experiences on substance abuse.

Child sexual abuse as a predictor of psychiatric co-morbidity and its implications for drug and alcohol treatment

A study of 180 women in and outside drug and alcohol treatment showed that CSA survivors had higher overall levels of psychological distress, compared with drug and alcohol treatment clients who had not experienced CSA. They reported elevated levels of anxiety, somatisation and dissociation but not depression. Higher rates of self-harm, eating disorders and sexual dysfunction were also reported by CSA survivors. Women with a history of both CSA and substance abuse were more likely to have attempted suicide than other women. The results highlight the need for improved liaison between substance abuse treatment programs and other health services.

Treatment of depression in the elderly: effect of physical illness on response

OBJECTIVES

To determine the response to treatment of different subgroups within a sample of physically ill elderly depressed patients.

DESIGN

Acute geriatric medical inpatients with depression, randomly assigned to an 8-week double-blind placebo-controlled trial of fluoxetine.

MAIN OUTCOME MEASURE

Response rate as defined by the 17-item Hamilton Depression Rating Scale.

RESULTS

Data were analysed in subgroups according to diagnosed physical problems and concomitant medication. A logistic regression analysis was performed to identify subgroups valid for separate analysis. Those reaching at least 5 weeks of treatment showed a significant improvement compared with the placebo group if they had serious life-threatening disease, cerebrovascular disease, were not demented, or were either on no analgesics or on analgesics stronger than paracetamol.

CONCLUSION

While the response to treatment in these subgroups was encouraging, general physicians must not be led to believe that the answer to depression lies only in pharmacological intervention, just as the belief that the risk-benefit ratio of such treatment where indicated is too high must be discouraged.

The effect of flash duration and flash shape on entrainment in Pteroptyx malaccae, a synchronic Southeast Asian firefly

Southeast Asian synchronic fireflies respond to stimulus flashes by phase-shifting their endogenous oscillator. This is called 'flash entrainment'. The releasers for entrainment were studied by changing stimulus flash shape and duration in Pteroptyx malaccae. Stimulus flash shapes and durations were synthesized digitally and delivered by a field-portable computer system. The computer also recorded male firefly flashes that were detected with a photometer. We found that the type of entrainment and its magnitude was influenced by the duration of the entrainment flash and by its shape.

Placebo-controlled treatment trial of depression in elderly physically ill patients

OBJECTIVES

To determine the response of physically ill elderly depressed patients to treatment.

DESIGN

Acute geriatric medical inpatients with depression, randomly assigned to an 8-week double-blind placebo-controlled trial of fluoxetine.

MAIN OUTCOME MEASURE

Response rate as defined by the 17-item Hamilton Depression Rating Scale.

RESULTS

Eighty-two patients entered the trial; 62 patients (all those who had completed at least 3 weeks of treatment) were included in the efficacy analysis. Forty-two completed the full 8 weeks (21 in each group) with response rates of 67% in the fluoxetine group and 38% in the placebo group. No significant difference was found between the responses of the two groups (p = 0.12). There was a trend for results in the fluoxetine group to continue to improve with time. On secondary analysis those patients with serious physical illness who completed 5 or more weeks (N = 37) showed a significant improvement in mood if treated with fluoxetine (p = 0.02).

CONCLUSIONS

The main benefit of antidepressants is to approximately double the chances of recovery. This trial showed the response rate of the fluoxetine treated group was increased by a factor of 1.8 over the placebo group in an 8-week period. The presence of physical illness, often severe and/or multiple, did not reduce the effectiveness of the medication, which was well tolerated overall. Those with serious physical disease responded significantly better to drug treatment; this will require further work. Psychological support was also considered to be important.

Predictors of graft patency 3 years after coronary artery bypass graft surgery. Department of Veterans Affairs Cooperative Study Group No. 297

OBJECTIVES

The purpose of this analysis was to define the factors that predict 3-year graft patency.

BACKGROUND

The success of coronary artery bypass graft surgery (CABG) is dependent on vein graft patency after the operation. It has been well established by a series of Department of Veterans Affairs Cooperative Trials that aspirin (325 mg daily) improves saphenous vein graft patency early (7 to 10 days) and at 1 year, but not at 3 years after CABG. This analysis, based on one of these trials, defined factors that predict 3-year graft patency.

METHODS

This analysis consisted of 266 patients, with 656 grafts that were patent 7 to 10 days after the operation, who underwent 3-year catheterization. To determine which patient-specific and/or graft-specific factors, or both, predict graft occlusion, a multivariate logistic regression analysis in terms of latent variables was used. It yielded a model that also took into account possible intraclass correlations.

RESULTS

For a vein graft that was patent at 7 to 10 days after the operation, the positive predictors, according to univariate analysis, for that graft being patent at 3 years were cross-clamp time < or = 80 min (p < 0.001), vein preservation solution temperature < or = 5 degrees C (p = 0.009), bypass time < or = 2 h (p = 0.042), number of proximal anastomoses < or = 2 (p = 0.018), operation time < or = 5 h (p = 0.044) and continuous versus intermittent cross-clamp technique (p = 0.024). There was also a trend with regard to recipient artery diameter > 1.5 mm (p = 0.063), serum cholesterol < or = 225 mg/dl (p = 0.084) and single versus sequential or Y vein graft (p = 0.060). Factors not predictive of 3-year patency were age, race, smoking history, high density lipoprotein cholesterol, vein source (thigh vs. calf), coronary artery grafted and aspirin treatment. Of all the predictors obtained in the univariate analysis, the only variables that were sufficient to yield a good model within the multivariate analysis were solution temperature (p = 0.004), serum cholesterol (p = 0.024), number of proximal anastomoses (p = 0.032) and recipient artery diameter (p = 0.034).

CONCLUSIONS

For a patient with patent vein grafts 7 to 10 days after the operation, predictors of 3-year graft patency are more closely related to operative techniques and underlying disease and not to aspirin treatment.

A qualitative study of barriers to formal treatment among women who self-managed change in addictive behaviours

Alcohol and drug abuse and dependence are common disorders in our society, and the vast majority of those who recover do so without formal treatment. Although this phenomenon appears to be more common among women than men there has been no gender-sensitive research. This qualitative study explored the barriers to formal treatment seeking among women who self-managed change in their alcohol and other drug dependence. The principal barriers identified included social stigma and labelling; lack of awareness of the range of treatment options, concerns about childcare, the perceived economic and time costs of residential treatment, concerns about the confrontational models used by some treatment services, and stereotypical views of clients of treatment services. A number of recommendations were made regarding program reach and content.

Characteristics of women with alcohol and other drug problems: findings of an Australian national survey

Two hundred and sixty-seven women were interviewed in a national survey examining the characteristics, treatment needs and treatment experiences of Australian women who had received treatment for their alcohol and other drug problems. More than half the women were mothers, of whom almost one-third had surrendered custody of their children. Polydrug use was the norm among these women, who in general had substantial experience with the legal system. A sizeable proportion of women had experienced physical and psychological health problems such as hepatitis, eating disorders, self-mutilation, suicide attempts and low self-esteem. The majority of the sample had a life-time history of physical or sexual violence. The implications of these findings are discussed and recommendations are provided for attracting and retaining women in appropriate services.

Immediate cardiac allograft failure. ECMO versus total artificial heart support

Optimal support for immediate cardiac allograft failure is unknown. With the introduction of heparin bonded extracorporeal membrane oxygenated circuits, prolonged cardiopulmonary support is possible. The authors report a case that involved 2 days of right atrial to ascending aorta extracorporeal membrane oxygenated support after immediate donor organ failure prevented the patient from exiting bypass. Continued deterioration in cardiac function led to an attempt at conversion to a total artificial heart as a bridge to retransplant. However, this procedure resulted in transbronchial exsanguination and recipient death. The autopsy showed pulmonary thrombosis with infarction and hemorrhage. The authors recommend caution in the use of extracorporeal membrane oxygenated support for patients with immediate and profound graft failure because of the increased risk of stasis thrombosis and pulmonary infarction due to sluggish pulmonary and left atrial blood flow. Instead, institution of total artificial heart or biventricular support may be preferable as the risks of thrombus and infarction are less.

Treatment needs and experiences of Australian women with alcohol and other drug problems

Two hundred and sixty-seven women were interviewed as part of a national survey examining the treatment needs and experiences of Australian women who had received assistance for their alcohol and other drug problems. The majority of women had previously received assistance for their substance use, and of these most had left alcohol and other drug treatment programs before completion. While the women cited a number of ways in which they were helped by such services, several areas were identified by the women as important and amenable to improvement. Among the service issues raised were access, models of service delivery, service structure and staffing, physical environment, physical and psychological safety and the handling of issues such as health status and sexual assault.

Use of cumulative meta-analysis in the design, monitoring, and final analysis of a clinical trial: a case study

From 1983 to 1987, the Department of Veterans Affairs (DVA) Cooperative Studies Program (CSP) conducted a multicenter clinical trial (CSP #207) to determine whether four different antiplatelet regimens compared to placebo could prevent the occlusion of grafts following coronary artery bypass surgery. The study showed that all of the active regimens tended to be better than placebo and that the three regimens containing aspirin were statistically significantly better. A cumulative meta-analysis of 12 trials performed shortly before the end of CSP #207 raised the issue as to whether the meta-analysis, if done earlier, would have changed the conduct of the trial. At the start of the planning period, one trail of size n = 37 had been published with a nonsignificant odds ratio (OR) of 0.74 (95% CI: 0.18, 3.12). At the time that CSP # 207 was approved by the DVA Cooperative Studies Evaluation Committee, two trials had been published (cumulative n = 150, OR = 0.44, 95% CI 0.19, 0.99). At the time patient intake started, five trials showed cumulative n = 769, OR = 0.42, 95% CI = 0.26, 0.68. Although the first 6-month CSP #207 progress report showed no treatment effect, by the time of the 12-month review by the Data Monitoring Board (DMB) a trend was developing in favor of active treatment. If the results of the meta-analysis had been available to the DMB at that time, conceivably the Board would have recommended stopping the placebo arm because of a convincing treatment effect based on the totality of the evidence. Cumulative meta-analysis could be useful as an adjunct in the planning, conduct, and final analysis of a clinical trial. It could also be used as one piece of evidence in the monitoring of the ongoing phase of a trial.

The tetracycline analogs minocycline and doxycycline inhibit angiogenesis in vitro by a non-metalloproteinase-dependent mechanism

The tetracycline analogs minocycline and doxycycline are inhibitors of metalloproteinases (MMPs) and have been shown to inhibit angiogenesis in vivo. To further study the mechanism of action of these compounds we tested them in an in vitro model of angiogenesis: aortic sprouting in fibrin gels. Angiogenesis was quantitated in this system by a unique application of planar morphometry. Both compounds were found to potently inhibit angiogenesis in this model. To further characterize the activity of these compounds against MMPs, we determined the IC50S of both compounds against representatives of three classes of metalloproteinases: fibroblast collagenase, stromelysin, and gelatinase A. Doxycycline was found to inhibit collagenase, gelatinase A and stromelysin with IC50S of 452 microM, 56 microM and 32 microM, respectively. Minocycline was found to inhibit only stromelysin in the micromolar range with an IC50 of 290 microM. Since these results suggest that these compounds may not have been inhibiting in vitro angiogenesis by an MMP-dependent mechanism, we decided to test the effects of the potent MMP inhibitor BB-94. This compound failed to inhibit aortic sprouting in fibrin gels, thus strongly suggesting that both doxycycline and minocycline act by an MMP-independent mechanism. These results have implications for the mechanism of action of tetracycline analogs, particularly where they are being considered for the treatment of disorders of extracellular matrix degradation including periodontal disease, arthritis, and tumor angiogenesis.

Avascular necrosis of bone after cardiac transplantation. Prevalence and relationship to administration and dosage of steroids

We studied the relationship of the administration and dosage of steroids to the development of avascular necrosis of bone in 168 patients who had had a heart transplantation (156 patients) or a heart and lung transplantation (twelve patients). One hundred and forty-one of the patients were male and twenty-seven were female. The average age was forty-five years (range, seven to sixty-six years). The average duration of follow-up was forty months (range, twelve to eighty months). Avascular necrosis developed in five patients (3 per cent). The femoral head was involved in three patients (bilaterally in two and unilaterally in one), the medial femoral condyle was involved bilaterally in one, and several sites were involved in the fifth patient. The avascular necrosis was diagnosed an average of five months (range, two to eleven months) after the transplantation. In order to evaluate the influence of the dosage of the steroids on the development of avascular necrosis of bone, the doses of prednisone and Solu-Medrol (methylprednisolone) at one week, one month, six months, and one year after the transplantation were calculated for each patient. There was no association between the cumulative dose of prednisone and the development of avascular necrosis. There was, however, a strong statistical association (p = 0.005), as determined with pooled two-tailed variance analysis, between the cumulative dose of Solu-Medrol administered in the first month after the transplantation and the development of avascular necrosis.

Long-term graft patency (3 years) after coronary artery surgery. Effects of aspirin: results of a VA Cooperative study

BACKGROUND

The long-term success of coronary bypass surgery is dependent on graft patency after surgery. This trial was designed to determine if aspirin improved saphenous vein graft or internal mammary artery (IMA) graft patency between 1 and 3 years after coronary artery bypass grafting (CABG).

METHODS AND RESULTS

After receiving aspirin 325 mg/d for 1 year after CABG and undergoing a 1-year postoperative cardiac catheterization, patients were randomized to receive either aspirin (325 mg) or placebo for 2 additional years. Angiography was performed 3 years after surgery to determine the primary end point-saphenous vein graft patency in 288 patients and IMA graft patency in 167 patients. At 3 years after CABG, the saphenous vein graft occlusion rate was 17.0% (62 of 365) for patients treated with aspirin compared with 19.7% (74 of 376) for those who received placebo (P = .404). For saphenous vein grafts that were patent at 1 year, the occlusion rate at 3 years was 4.8% (15 of 313) for patients treated with aspirin compared with 4.2% (13 of 310) for patients who received placebo (P = .757). At 3 years, the IMA graft occlusion rate was 10.3% (8 of 78) for patients treated with aspirin compared with 7.9% (7 of 89) for patients who received placebo (P = .594). For IMA grafts that were patent at 1 year, the occlusion rate was 4.3% (3 of 70) for patients treated with aspirin compared with 2.5% (2 of 81) for patients who received placebo (P = .541).

CONCLUSIONS

These data suggest that aspirin treatment does not improve saphenous vein graft or IMA graft patency between 1 and 3 years after CABG.

Avascular necrosis superimposed on Legg-Calvé-Perthes disease in a cardiac transplant patient

The pathogenesis of both Legg-Calvé-Perthes disease (LCPD) and avascular necrosis (AVN) remains controversial. Evidence suggests, however, that both conditions are produced by vascular compromise in the femoral head. A patient with a previous history of LCPD at age eight subsequently developed AVN at age 46 after having a cardiac transplant for ischemic cardiomyopathy. A review of the past ten years' literature disclosed no reports of similar cases.

Pediatric retransplantation

Previous studies have attempted to outline the efficacy of heart retransplantation in adults. A limited number of these retransplantation procedures have been performed in children; however, no study to date has evaluated the risk of heart retransplantation in this specific patient population. We conducted a retrospective review of 17 pediatric (non-neonatal) heart transplant recipients who subsequently underwent heart retransplantation. Thirteen male and four female patients underwent retransplantation at four different institutions between 1974 and 1992. Patient age at the time of primary transplantation ranged from 2 to 19 years (mean, 12.5 years) and from 3 to 30 years (mean, 16 years) at retransplantation. The time interval between transplantation procedures ranged from 2 days to 15.6 years and was not predictive of patient outcome. Follow-up after retransplantation ranged from 1 day to 11 years (mean, 2.8 years). All patients were New York Heart Association class 3 or class 4 at the time of retransplantation. After retransplantation all survivors were New York Heart Association class 1. No patient had mechanical device implantation or extracorporeal membrane oxygenation bridge-to-transplantation at primary transplantation or retransplantation. The indication for retransplantation was transplant coronary artery disease (TxCAD) in seven patients (41.2%), acute rejection in four (23.5%), chronic rejection in one (5.8%), chronic rejection associated with TxCAD in four (23.5%), and intraoperative donor organ failure in one (5.8%). No significant difference occurred in linearized rates of rejection or infection or in actuarial freedom from rejection or infection when secondary grafts were compared with primary grafts in patients undergoing retransplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of a specialist women's alcohol and other drug treatment service with two traditional mixed-sex services: client characteristics and treatment outcome

Eighty subjects from a specialist women's service (SWS) and eighty subjects from two traditional mixed-sex treatment services (TMS) were recruited to a comparative, longitudinal study of changes in alcohol and other drug associated problems. Both the SWS and the TMS programs were principally based on the traditional disease model and the 12-step philosophy but the SWS employed only female staff and provided residential childcare. The SWS succeeded in attracting significantly more lesbian women, women with dependent children, women sexually abused in childhood and with a maternal history of substance dependence than the TMS. Six months following treatment there were no significant differences in any measure of treatment outcome between the two treatment groups. The results suggest that the simple provision of women-only treatment and childcare without changing treatment content does not substantially improve treatment outcome in women with severe alcohol and other drug related problems.

A comparison of women seeking drug and alcohol treatment in a specialist women's and two traditional mixed-sex treatment services

The paucity of research on the treatment needs of women with substance abuse problems has been a serious impediment to the development of empirically validated treatment programmes. Women continue to be seriously under-represented as research subjects and clients of treatment services. This study compares the characteristics of 80 women attending a specialist women's treatment service with those of eighty women attending two traditional mixed-sex treatment agencies. Women attending a gender-sensitive service were significantly more likely to have dependent children, to be lesbian, to have a maternal history for drug or alcohol problems and to have suffered sexual abuse in childhood. These results suggest that gender-sensitive treatment services may be recruiting women who might not otherwise have sought treatment for their substance dependence problems.

A comparison of predictors of treatment drop-out of women seeking drug and alcohol treatment in a specialist women's and two traditional mixed-sex treatment services

The problem of high levels of client drop-out in drug and alcohol treatment is frequently reported in the literature. In the course of conducting an evaluation of a specialist women's treatment service, the inadequacy of the data on women-specific predictors of treatment drop-out was highlighted. Using a retrospective design, the characteristics of 160 women who left treatment less than 5 days after admission were compared to the 160 women who stayed longer than 5 days and were enrolled in the evaluation study. The findings of this study suggested that women who were employed, had a history of sexual assault (especially in adulthood), nominated alcohol as their drug of choice, were not married, older than 25 years of age and had demonstrated a sympathy with the agency's treatment philosophy were less likely to drop-out of treatment. In addition, for lesbian women, women with a history of sexual assault in childhood, and those with dependent children, attendance at a specialist women's service reduced the incidence of treatment drop-out.

The prevalence of dementia among elderly people living in Zaragoza and Liverpool

The prevalence of dementia in elderly people living in the community was compared using data from Zaragoza (Spain) and Liverpool (UK). A standardized interview, the Geriatric Mental State (GMS), was administered to a random sample of 1070 persons in Liverpool and 1080 in Zaragoza. Using diagnoses derived from the GMS-AGECAT package we found no significant difference between the prevalence of dementia in Zaragoza (7.4%) and Liverpool (5.0%). The expected increase in prevalence with age was found, but the two cities did not appear to differ in the relationship between age and prevalence. No sex difference was apparent, and the two cities do not differ in the relationship between sex and prevalence.

Starting aspirin therapy after operation. Effects on early graft patency. Department of Veterans Affairs Cooperative Study Group

BACKGROUND

Although aspirin therapy started before operation improves vein graft patency after coronary artery bypass grafting, it also causes bleeding. The objective of this prospective, centrally directed, randomized, double-blind, placebo-controlled trial was to compare the effects of aspirin therapy started before operation with aspirin started 6 hours after operation on early (7-10-day) graft patency.

METHODS AND RESULTS

Patients were randomized to receive either aspirin 325 mg or placebo the night before surgery; after operation, all patients received aspirin 325 mg daily, with the first dose administered through the nasogastric tube 6 hours after operation. Angiography was performed in 72% of the analyzed patients an average of 8 days after operation, and the primary end point was saphenous vein graft patency in 351 patients. Internal mammary artery graft patency was also assessed in 246 patients because many individuals received both internal mammary artery and vein grafts. In the patients given preoperative aspirin, the vein graft occlusion rate was 7.4 +/- 1.3% compared with 7.8 +/- 1.5% in those who received preoperative placebo (p = 0.871). In the subgroup of patients receiving Y grafts, 0.0% of the grafts were occluded in the preoperative aspirin group compared with 7.0 +/- 3.6% in the preoperative placebo group (p = 0.066). The internal mammary artery occlusion rate was 0.0% (0 of 131) in the aspirin group compared with 2.4 +/- 1.4% (three of 125) in the placebo group (p = 0.081). Patients in the aspirin group received more transfusions than those in the placebo group (median, 900 versus 725 ml, p = 0.006). The reoperation rate for bleeding in the aspirin group was 6.3% compared with 2.4% in the placebo group (p = 0.036). Median chest tube drainage within the first 6 hours after operation was 500 ml in the aspirin group compared with 448 ml in the placebo group (p = 0.011).

CONCLUSIONS

Thus, preoperative aspirin is associated with increased bleeding complications and offers no additional benefit in early vein graft patency compared with starting aspirin therapy 6 hours after operation. There was a trend, although not significant, toward improved early patency for Y grafts and internal mammary artery grafts with preoperative aspirin.

Long-term follow-up comparing subclavian flap angioplasty to resection with modified oblique end-to-end anastomosis

The definitive surgical procedure for correction of aortic coarctation remains controversial. Therefore, we retrospectively reviewed a total of 56 children under 4 years of age with coarctation repair between 1977 and 1986. Thirty-four had the subclavian flap angioplasty technique and 22 had resection with oblique end-to-end anastomosis. The group was further subdivided to include only the 23 infants less than 3 months of age--eight infants with resection with oblique end-to-end anastomosis (less than or equal to 3ETE) and 15 infants with subclavian flap angioplasty (greater than or equal to 3SFA). The remaining 33 patients older than 3 months of age were divided into 14 patients with resection and oblique end-to-end anastomosis (greater than 3ETE) and 19 patients with the subclavian flap angioplasty technique (greater than 3SFA). The overall mortality was not significantly different between techniques. Postoperative hypertension was significantly more prevalent with end-to-end anastomosis than with the subclavian flap angioplasty technique (p less than 0.01). Seven patients had recurrent coarctation. The 6-year actuarial freedom from recoarctation was 93% +/- 6% in the less than or equal to 3SFA group compared with 53% +/- 20% in the less than or equal to 3ETE group (p less than 0.02), but there was no significant difference in those children operated on at a later age regarding the type of coarctation repair. Therefore, we recommend subclavian flap angioplasty in patients less than 3 months of age. In those older than 3 months either procedure is safe and the risk of recoarctation is similar.

Internal mammary artery and saphenous vein graft patency. Effects of aspirin

As part of two Department of Veterans Affairs Cooperative Trials, we obtained angiographic patency data for internal mammary artery (IMA) and saphenous vein grafts to the left anterior descending (LAD) coronary artery at 1 year after coronary artery bypass surgery. Patients received either aspirin 325 mg q.d., aspirin 325 mg t.i.d., aspirin 325 mg and dipyridamole 75 mg t.i.d., or placebo. Aspirin was initiated either 12 hours before or 6 hours after operation. Patients were stratified preoperatively for extent of disease and randomized to the therapies outlined above. There was no randomization to IMA versus saphenous vein grafts to the LAD. When the patients taking placebo were compared with those taking aspirin, there were no differences in the IMA (100.0% versus 92.1%, p = 0.385) or vein graft (88.8% versus 90.4%, p = 0.675) patency rates. The patency rate, irrespective of treatment, for all IMA grafts was 92.8% (220 of 237) versus 90.1% (345 of 383) for all vein grafts to the LAD (p = 0.309). Thus, both the IMA and vein grafts had excellent patency rates at 1 year. Aspirin did not alter this at 1 year, and there were no differences between IMA and vein graft patency to the LAD.

Heart-lung transplantation: the initial Arizona experience

Since November 1985, cardiopulmonary transplantation has been performed at the University of Arizona heart transplant program. Seven patients, five women and two men, have undergone heart-lung transplantation. Five patients had primary pulmonary hypertension, and two patients had Eisenmenger's complex. The mean age was 31 years (range, 17 to 43 years). Average follow-up was 15 months (range, 3 to 34 months), with a total of 115 patient-months. There have been no operative or late deaths. Immunosuppression consisted of rabbit antithymocyte globulin, cyclosporine (Cyclosporin A), azathioprine, methylprednisolone, and prednisone. Our first five patients were aggressively diagnosed and treated for rejection by endomyocardial biopsy, with each patient having one or several treatments for acute rejection. These five patients had one or several episodes of severe infection, particularly cytomegalovirus. In our last two patients we omitted routine heart biopsies. Only those rejection episodes diagnosed by chest x-ray films are considered significant. Our last two patients have not been treated for acute rejection and have had no infections. Presently our immunologic surveillance consists only of careful clinical examination and frequent chest x-ray films. Any changes in the patient's condition are aggressively investigated, searching for infection or rejection. Two patients have been used as domino donors of their native heart.