Creating a DIN to tackle drug-related deaths in the community

Brighton and Hove has one of the highest rates of drug-related deaths in the UK. The deceased commonly have had contact with a number of organizations isolated from each other. The aim of this study was to explore aspects of drug addiction in Brighton as the first stage in the creation of a local Drug addiction Intervention Network (DIN) and to make recommendations about improving the effectiveness of medical contacts so that modifiable risk factors could be addressed appropriately and consistently. The coroner's records of the drug-related deaths in 1998 for Brighton and Hove were cross-referenced with computerized records of the Accident & Emergency department of the local hospital and the police station. Of the 36 drug misusers who died during the year, most were male, mean age 34 years. Alcohol was a common comorbid finding. Seventy-eight per cent were known to the A&E department and 62% had been arrested locally during 1997 or 1998. Such retrospective data can only give limited information. We, therefore, performed a prospective survey. It was carried out by the forensic medical examiner (FME) in 1997-1998, interviewing 41 arrestees to give a profile of the criminally involved drug misusers. With the information obtained, the A&E doctors and FMEs were able to review the medical advice given and establish a protocol for the transfer of severely intoxicated arrestees.

Randomized phase II study of two irinotecan schedules for patients with metastatic breast cancer refractory to an anthracycline, a taxane, or both

PURPOSE

A pressing need exists for agents active against anthracycline- or taxane-refractory metastatic breast cancer (MBC), or both. Previous clinical trials suggested that irinotecan might have such activity. We conducted this multicenter phase II study to assess efficacy and tolerability of two irinotecan schedules.

PATIENTS AND METHODS

MBC patients who experienced disease progression after one to three chemotherapy regimens, including at least one anthracycline- or taxane-based regimen, were randomly assigned to irinotecan in 6-week cycles comprising 100 mg/m(2) weekly for 4 weeks, then a 2-week rest (weekly) or 240 mg/m(2) every 3 weeks.

RESULTS

The weekly arm had 52 assessable patients; the every-3-weeks arm had 51 assessable patients. In the weekly arm, the objective response (complete regression [CR] + partial regression [PR]) rate was 23% (one CR, 11 PR; 95% CI, 13% to 37%). Median response duration was 4.9 months (range, 1.9 to 15.9 months), and median overall survival was 9.7 months (95% CI, 8.0 to 14.2 months). In the every-3-weeks arm, the objective response rate was 14% (nine PR; 95% CI, 6% to 26%), median response duration was 4.2 months (range, 3.1 to 13.9 months), and median overall survival was 8.6 months (95% CI, 7.0 to 12.3 months). Treatment generally was well tolerated, especially in the weekly arm. Grade 3 to 4 adverse events with > or = 10% incidence included neutropenia (29%) and diarrhea (17%) in the weekly arm and neutropenia (36%), vomiting (20%), dyspnea (18%), nausea (16%), and diarrhea (12%) in the every-3-weeks arm.

CONCLUSION

Irinotecan is active with good tolerability in refractory MBC. Irinotecan (especially weekly) warrants additional study as monotherapy and in combination regimens in this setting.

Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE): Alzheimer's disease trial

This article describes the development of the protocol for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Alzheimer's disease trial, which was developed in collaboration with the National Institute of Mental Health to assess the effectiveness of atypical antipsychotics for psychosis and/or agitation occurring in outpatients with Alzheimer's disease. The article provides a detailed description of the methodology used in the trial as well as the clinical outcomes and effectiveness measures incorporated into it, discussing the most salient issues encountered in developing the design of the trial, as well as the unique features of the trial.

Fast-track surgical referral in a population displaced by war and conflict

After the 1988-1994 conflict between Armenia and Azerbaijan, fought over the territory of Nagorno-Karabakh, large numbers of people were resettled in camps in southern Azerbaijan. Healthcare in the camps was generally good but there was no access to hospitals. The Leonard Cheshire Centre of Conflict Recovery (LCC) organized a 'fast-track' system of surgical care in the southern camps by securing the help of still-functioning hospitals in the distant capital, Baku. Regular clinics were held in the camps for visiting specialists; and, by arrangement with the Government of Azerbaijan and various non-governmental organizations, treatment was offered to those who fell within strict selection criteria. After a pilot study yielded clear benefits, the scheme was transferred to a local non-governmental organization, which successfully operated an expanded version. The hidden cost of war often includes the neglect of chronic medical conditions that require secondary and tertiary care. The 'fast-track' system illustrates the potential of existing facilities to meet these needs at modest cost, given sufficient support.

Fast-track surgical referral in a population displaced by war and conflict

After the 1988-1994 conflict between Armenia and Azerbaijan, fought over the territory of Nagorno-Karabakh, large numbers of people were resettled in camps in southern Azerbaijan. Healthcare in the camps was generally good but there was no access to hospitals. The Leonard Cheshire Centre of Conflict Recovery (LCC) organized a 'fast-track' system of surgical care in the southern camps by securing the help of still-functioning hospitals in the distant capital, Baku. Regular clinics were held in the camps for visiting specialists; and, by arrangement with the Government of Azerbaijan and various non-governmental organizations, treatment was offered to those who fell within strict selection criteria. After a pilot study yielded clear benefits, the scheme was transferred to a local non-governmental organization, which successfully operated an expanded version. The hidden cost of war often includes the neglect of chronic medical conditions that require secondary and tertiary care. The 'fast-track' system illustrates the potential of existing facilities to meet these needs at modest cost, given sufficient support.

Mood stabilizers in Alzheimer's disease: symptomatic and neuroprotective rationales

OBJECTIVE

This paper provides a case study of 'reverse translational research', in which empirical clinical trials focused on relieving psychopathological symptoms of Alzheimer's disease (AD) ultimately led to mechanism-based trials addressing aspects of the underlying pathophysiology of Alzheimer's disease. AD is multi-dimensional in nature, characterized not only by cognitive and functional decline but by neuropsychiatric symptoms that develop commonly and are associated with considerable morbidity. There have been a large number of empirical trials of various pharmacological agents to reduce these symptoms, such as agitation. Although antipsychotics are used most frequently for agitation, the usual effect size is modest, and there is a range of tolerability and/or safety issues, leading to the hope that alternatives can be found. Furthermore, most clinical trials addressing psychopathology have not been mechanism-based and none have attempted an alternative approach, namely, to delay or prevent the emergence of psychopathology.

FINDINGS

The evidence of clinical trials is reviewed regarding the safety, tolerability, and apparent efficacy of the mood stabilizers carbamazepine and valproate for agitation associated with AD. Possible mechanisms of action of valproate are reviewed, leading to the surprising conclusion that neuroprotective properties may account for some of its clinical effects. These mechanisms (including activation of wnt-dependent signaling and upregulation of bcl-2, among others) may be particularly relevant for long-term treatment of AD.

CONCLUSIONS

These clinical and mechanistic findings were combined in the development of a novel clinical trial examining whether chronic valproate therapy can attenuate the clinical progression of AD, which will be implemented by the Alzheimer's Disease Cooperative Study. The design addresses valproate's potential to delay or prevent the onset of agitation in patients lacking agitation to begin with, as well as to slow progressive decline in cognition and daily functioning.

Psychopharmacologic interventions in nursing homes: what do we know and where should we go?

Psychiatric symptoms are common among individuals who live in nursing homes, with prevalence rates ranging from 51 percent to 94 percent. Accordingly, psychotropic medications are widely prescribed in this setting and are the subject of considerable debate and regulation. Current regulations arose from public and governmental concerns that psychiatric medications were being prescribed inappropriately to frail patients. Concern has also been raised about the absence of evidence on which to base prescribing decisions. Nursing homes are slowly being recognized as complex health care settings that warrant considerable research attention. This article explores the origins of the regulation of the use of psychotropic drugs in nursing homes, reviews controlled trials of these drugs in nursing homes, examines the role of these agents in adverse drug events experienced by nursing home residents, and proposes policy and research areas that merit consideration.

Functional, dynamic, and anatomic MR urography: feasibility and preliminary findings

RATIONALE AND OBJECTIVES

The authors assessed the feasibility of using magnetic resonance (MR) urography to acquire functional, dynamic, and anatomic information in human subjects with normal and hydronephrotic kidneys.

MATERIALS AND METHODS

In subjects known to have or suspected of having hydronephrosis, split renal filtration fractions were measured with a customized magnetization-prepared, inversion-prepared gradient-recalled echo sequence to determine the T1 of flowing blood in the inferior vena cava and aorta before and after contrast medium administration and in the renal veins and arteries after contrast medium administration. Multiple timed sets of coronal fast spoiled gradient-echo 70 degrees flip-angle images were acquired before and after contrast medium administration to derive MR renograms from changes in the signal intensity of the cortex and medulla. Precontrast T2-weighted images were obtained with a three-dimensional fast spoiled gradient-echo maximum intensity projection pulse sequence, and postcontrast T1 maximum intensity projection images were also obtained to depict the renal anatomy.

RESULTS

Split filtration fraction differentiated normal from hydronephrotic kidneys. MR renograms depicted vascular, tubular, and ductal phases and differentiated between normal and hydronephrotic kidneys (P < .05, n = 20). Contrast medium dose correlated with the peak of the cortical signal intensity curves on the renogram (r = 0.7, P < .0005; n = 20). The sensitivities for the visual determination of hydronephrosis and unilateral delayed excretion of contrast material were both 100%, and the specificities were 64% and 85%, respectively.

CONCLUSION

The preliminary findings show promise for the use of MR urography in the comprehensive assessment of renal function, dynamics, and anatomy.

Nonlocalized lower gastrointestinal bleeding: provocative bleeding studies with intraarterial tPA, heparin, and tolazoline

PURPOSE

The purpose of this study was to assess the efficacy and safety of provocative mesenteric angiography with tissue plasminogen activator (tPA), heparin, and tolazoline in patients with nonlocalized lower gastrointestinal (LGI) bleeding. Results were examined to assess the clinical impact of the study on patients who had positive or negative results from elective provocative bleeding studies.

MATERIALS AND METHODS

Seventeen provocative bleeding studies for occult LGI bleeding were performed in 16 patients, nine of whom were women, aged 44-79 years. All patients had negative results from previous endoscopic and angiographic studies. Patients' requirements for blood transfusion ranged from 6 to 69 units. Studies were performed electively. Blood group matching and cross-matching were performed for all patients. To provoke bleeding, a combination of intravenous heparin, intraarterial tolazoline, and intraarterial tPA was used. Doses used included 3,000-10,000 U heparin, 25-100 mg intraarterial tolazoline, and 10-50 mg intraarterial tPA (mean, 20.3 mg). Duration of follow-up was 3-34 months.

RESULTS

Seventeen elective provocative studies were performed in 16 patients with occult LGI bleeding, leading to provoked bleeding in six patients (37.5%). In addition, two previously undiagnosed vascular abnormalities were diagnosed, which did not bleed during provocation. Therefore, an abnormality was identified in eight of 16 patients (50%) overall. There were no procedural complications encountered during or after any of the 17 procedures. In six patients in whom bleeding was successfully provoked, four bleeding episodes occurred in the large bowel and two occurred in the small bowel. Five of the positively provoked patients had a previously positive tagged red cell scintigraphic study. Three patients had superselective embolization at the time of provoked bleeding. Two were treated with estrogen therapy, and one patient was treated palliatively. Five of these six patients required no further therapy for LGI bleeding. Ten patients (including two with vascular abnormalities) did not bleed during the provoked study with tPA. Follow-up of the group of eight patients with completely normal study results ranged from 3 to 34 months in duration, and during the follow-up period, five patients experienced repeated bleeding and one had no further bleeding. One patient was diagnosed with an ileal vascular lesion during subsequent intraoperative enteroscopy and underwent surgical resection. One patient was lost to follow-up.

CONCLUSION

Intraarterial provocative mesenteric angiography with heparin, vasodilator, and tPA identified the site of bleeding in 37.5% of patients in our study group and contributed to treatment in 50%. This small study indicates that the procedure appears to be safe, with no complications encountered in this series. Larger prospective studies are needed to fully assess the safety and efficacy of the technique and to optimize the pharmacologic protocol and patient selection.

Impact of molecular medicine on neuropsychiatry: the clinician's perspective

Clinical neuropsychiatry has traditionally relied on individual practitioner experience or the apprentice-training model for formulating cases and choosing treatment. Scientifically-based diagnostic criteria and treatment algorithms have been lacking in the overlap area between psychiatry and neurology, owing largely to the complexity of this population population. However, the novel application of new molecular technologies is promising to change the care of neuropsychiatric patients. This review will highlight recent advances in molecular medicine pertaining to neuropsychiatry.Introduction

Health Insurance family style: public approaches to reaching the uninsured

This issue brief explores existing and potential opportunities to further expand the availability of health coverage for the uninsured and the under insured, given the current economy and the resulting state budget shortfalls. It also considers the implications of the Health Insurance Flexibility and Accountability initiative recently announced by the Centers for Medicare and Medicaid Services and the legislative options for health care reform being debated in Washington, including tax-credit incentives and additional federal funding for public coverage expansions through Medicaid and the State Children's Health Insurance Program. The Forum session will explore state, federal, and academic perspectives on public coverage expansions and the variety of paths available to support such expansions. The meeting will also address the cost implications of the differing perspectives in the context of the shifting economy. This is expected to lead to a discussion among presenters and participants of the future of and priorities for public financing of health insurance coverage.

Value of high-performance liquid chromatographic analysis of anthocyanins in the differentiation of red grape cultivars and red wines made from them

A HPLC method that allows the separation of several anthocyanins present in red grapes and red wines, using a linear gradient of acetonitrile in water at pH 1.3, using perchloric acid as an acid modifier, is described. Data clearly show that the anthocyanins profile of red grapes may be complex, but quite different for each cultivar studied. Thus, those molecules may be used as chemotaxonomic markers for classifying red grape cultivars. However, the anthocyanin profile of red wines clearly differs from that presented by grapes employed in making it, because red wine contains a higher relative amount of malvidin-3-O-glucoside than grapes, and the relative amount of other anthocyanins in wines is usually lower than in grapes. Therefore, the use of anthocyanins present in wines to determine the grape cultivar used for winemaking needs a careful evaluation of the influence of different technological procedures on the anthocyanins fingerprint.

Pharmacologic therapy for behavioral symptoms of alzheimer's disease

Behavioral signs and symptoms in dementia are common, morbid, classifiable, and treatable. The current state-of-the-art approach is to evaluate carefully for social or environmental causes, intercurrent medical conditions, or other triggers of the behavior and attempt to deal with those directly. When these conservative steps fail, there may be a role for medication. A rational approach typically hinges on matching the most dominant behavioral target symptoms to the most relevant medication class, the key information of which is summarized.

Assessing the competence of persons with Alzheimer's disease in providing informed consent for participation in research

OBJECTIVE

The capacity of persons with Alzheimer's disease or other neuropsychiatric disorders for giving consent to participate in research has come under increasing scrutiny. While instruments for measuring abilities related to capacity have been developed, how they should be used to categorize subjects as capable or incapable is not clear. A criterion validation study was carried out to help address this question.

METHOD

The authors measured the ability of 37 subjects with mild-to-moderate Alzheimer's disease and 15 elderly comparison subjects to provide consent for participation in a hypothetical clinical trial. Using the judgment of three experts as the criterion standard, the authors performed a receiver operator characteristic analysis for the capacity ability measures from the MacArthur Competence Assessment Tool-Clinical Research VERSION: The results were compared with categorizations of capacity status that were based on normative values.

RESULTS

While most comparison subjects scored perfectly on all measures of the competence assessment tool, the majority of the group with Alzheimer's disease showed significant decision-making impairment. Thresholds based on normative values resulted in 84% (N=31) of the Alzheimer's disease subjects being rated as incapable on at least one ability; thresholds based on expert judgment resulted in 62% (N=23) failing to meet cutoff scores on at least one ability.

CONCLUSIONS

Even relatively mild Alzheimer's disease significantly impairs consent-giving capacity. But differentiating capable from incapable subjects remains an issue despite the aid of standardized tools. More research is needed to understand the relationship between subject factors (performance on ability measures) and categorical judgments about their capacity.

Clostridium novyi infection: a fatal association with injecting drug users

Injecting drug users frequently use accident and emergency (A&E) departments to access emergency care for local and systemic infections. Clostridium novyi type A is a bacterium that has recently been associated with a number of fatalities among drug injecting addicts. The clinical course is described of a patient who attended an A&E department with septicaemia who was found at postmortem examination to have been infected with Clostridium novyi type A. Doctors working in A&E departments should be aware of the existence of this infection and be vigilant when treating injecting drug users with localised infection.

Topographic position of forelimb motoneuron pools is conserved in vertebrate evolution

The neuromotor conservatism hypothesis predicts that neuromotor patterns in homologous tetrapod muscles are conserved evolutionarily despite the musculoskeletal modifications of vertebrate limbs. A complete description of the anatomical organization of the neurons innervating homologous limb muscles is a prerequisite to any test of the neuromotor conservatism hypothesis. This study uses the retrograde neuronal tracer WGA-HRP to selectively label the motor neuron pools of seven homologous forelimb muscles in mice (Mus musculus) and iguanas (Iguana iguana): Mm. pectoralis, spinodeltoideus, biceps brachii, lateral and long heads of triceps brachii, and the supraspinatus and infraspinatus (in mice) or their reptilian homolog, the supracoracoideus (in iguanas). In vertebrates, motoneurons are arranged in longitudinal columns of cells in the ventral horn of the spinal cord. Mouse motor pools average 1,952 microns in length, except the pectoralis pool which averaged 2,949 microns in length. Iguana pools average 3,196 microns in length. The number of neurons per pool ranged from 70-199 in mice and from 58-114 neurons in iguanas. In both iguanas and mice the motor pools for the spinodeltoids, biceps, and the supracoracoideus (or its mammalian homologs) lie anterior to the pectoralis and triceps motor pools. In the transverse plane, the pectoralis pool lies medial to those of the triceps. The pools of the biceps and spinodeltoids are located dorsal and lateral to those of the pectoralis and supracoracoideus (or its homologs in mammals). The resulting motor pool maps support the hypothesis that the anatomical organization of motoneurons in ancestral reptiles has been retained in these two tetrapod descendents.

White coat effect of alcohol

Numerous studies have shown a relationship between alcohol intake and elevated clinic blood pressures (BP). However, there have been few studies on the relationship between alcohol consumption and 24-h ambulatory BP monitoring. This study aimed to determine the relationship between alcohol intake, clinic BP, and 24-h ambulatory BP recordings to determine to what extent a white coat effect may contribute to the relationship between alcohol consumption and BP. Clinical BP and 24-h ambulatory BP were measured in 121 male volunteers aged 50.6 +/- 9.8 years (range, 30-70 years) who consumed between 0 and 2050 g of alcohol per week (mean, 394 +/- 342 g; median, 385 g/week). Supine clinical systolic BP (SBP) was significantly related to alcohol intake (beta = 0.242; P = .007). Alcohol consumption was not related to 24-h mean SBP or diastolic BP (DBP), daytime SBP or DBP, or nighttime SBP or DBP (daytime SBP: beta = 0.02, P = .802). Alcohol intake was significantly related to the difference between clinic SBP and mean daytime SBP (beta = 0.260, P = .004). Twenty-four-hour mean heart rate (HR), daytime mean and nighttime mean HR were strongly associated with alcohol intake (24-h HR: beta = 0.455, P < .001). These results suggest that the association between alcohol consumption and elevated BP is contributed to by a significant white coat effect and that excessive alcohol consumption may be a significant factor in explaining differences between clinic and ambulatory BP measurements.

Conversion of indwelling chest port catheters to tunneled central venous catheters

PURPOSE

To determine the safety and efficacy of the conversion of subcutaneous chest wall infusion ports to tunneled central venous catheters.

MATERIALS AND METHODS

During a period of 34 months, 67 patients were referred for conversion of indwelling subcutaneous chest wall ports to tunneled central venous catheters as part of a bone marrow transplant protocol. Six patients were deemed unacceptable for conversion and the remaining 61 underwent successful conversion. All patients had functioning surgically placed single-lumen (n = 50) or double-lumen (n = 11) chest ports, which were removed to maintain the original venous access sites for placement of a tunneled central venous catheter, incorporating the chest wall pocket for tunneling, in 46 patients (75%). A new tunnel was created in the other 15 patients. There were no immediate complications and all patients were followed until catheter removal or patient demise with the catheter in place.

RESULTS

57 of 61 (93%) catheters were used without evidence of infection for 23-164 days (mean, 57 d) after placement. Two (3%) were removed (both at 26 days) because of persistent neutropenic fever without physical signs or laboratory evidence of catheter infection, and two (3%) were removed (at 11 and 77 days) because of proven catheter infection, yielding an overall infection rate of 1.2 per 1,000 catheter days. Two catheters required exchange and two required stripping because of decreased function, resulting in an overall catheter-related complication rate of 2.4 per 1,000 catheter days.

CONCLUSIONS

Indwelling subcutaneous chest wall infusion ports can be safely converted to tunneled central venous catheters, even in an immunocompromised patient population, with a low risk of complications such as infection.