Development of Mobile Contingency Management for Cannabis Use Reduction

Many interventions for cannabis use disorder (CUD) are associated with decreases in frequency and quantity of use but fail to increase overall rates of sustained abstinence. It is currently unknown whether reductions in use (in the absence of sustained abstinence) result in clinically significant improvements in functioning. The objective of this study was to refine a mobile contingency management approach to reduce cannabis use to ultimately evaluate whether reductions in frequency and quantity of cannabis are related to improvements in functional and mental health status. Three cohorts of participants (n = 18 total, n = 10 women) were enrolled and completed 2 weeks of ecological momentary assessment (EMA) during a baseline ad lib cannabis use period, followed by a 6-week reduction period. Participants completed EMA assessments multiple times per day and were prompted to provide videotaped saliva cannabis testing 2-3 times daily. Data from participants who were at least 80% adherent to all EMA prompts were analyzed (13 out of 18). During the ad lib phase, participants were using cannabis on 94% of the days and reported using a mean of 1.42 grams daily. The intervention was a mobile application that participants used to record cannabis use by saliva tests to bioverify abstinence and participants completed electronic diaries to report their grams used. During the 6-week intervention phase, participants reported reducing their use days to 47% of the days with a reported mean of .61 grams daily. In the last cohort, at least 50% of the heavy users were able to reduce their cannabis use by at least 50%. The effect of cannabis reduction (versus abstinence) is largely unknown. Observations suggest that it is possible to develop a mobile intervention to reduce cannabis use among heavy users, and this paradigm can be utilized in future work to evaluate whether reductions in cannabis use among heavy users will result in improvements in functional and mental health status.

Compartment Syndrome Resulting From Improper Intraosseous Cannulation: A Case Report

Obtaining adequate vascular access is imperative for effective resuscitative, therapeutic, and diagnostic interventions. The intraosseous (IO) route is indicated when immediate vascular access is needed, and standard central or peripheral intravenous (IV) access is unattainable or would delay therapy in a critical patient. We present a rare case of improper IO line placement in the right proximal tibia of a 30-year-old female involved in a motor vehicle collision, resulting in extravasation of blood products into the surrounding tissue and development of acute compartment syndrome. Emergency Medical Services was unable to obtain IV access in a timely manner, thus a right proximal tibia 45mm IO line was placed, and a unit of whole blood was given with a high-pressure infusor in the field. At the trauma center, the patient's right lower extremity was severely tense and edematous with no palpable right lower extremity pulses and no Doppler signals. Computed tomography revealed the IO catheter extending through both the proximal and distal cortices of the right tibia. Medial and lateral fasciotomy of the right lower extremity was performed in which all four compartments of the right lower leg were released and a significant hematoma was evacuated from the superficial posterior compartment. This case highlights the importance of IO access as a life-saving intervention while also underscoring the need to educate and familiarize pre-hospital and hospital healthcare personnel in delivering IO access so as to mitigate risks and improve outcomes for critically ill patients.

Persistent pseudoaneurysm after non-operative management of a Grade 4 liver injury

A hepatic pseudoaneurysm (HPA) after blunt or penetrating liver injury is an unusual but potentially lethal complication that can develop from an injured hepatic artery branch [1-5]. Endovascular intervention with coil embolization to treat HPA is a safe and effective method and has become the standard first-line treatment, with a success rate achieving 70-100 % [13,14,15]. Infrequently the pseudoaneurysm is fed by collateral vessels and endovascular intervention may be unsuccessful. Other minimally invasive treatment options that can be considered include image guided percutaneous thrombin injection, endovascular placement of covered stents and injection of liquid agents such as fibrin glue [10,11]. We present a case of a young female who developed a post-traumatic persistent hepatic pseudoaneurysm requiring a total of nine interventions, including six endovascular interventions with angiography, three endoscopic procedures for bleeding, one percutaneous injection, and two re-admissions to the hospital. Although she avoided initial operative management, her three-month hospital course can be considered a failure of conservative management of blunt hepatic trauma due to the accrued health care costs and resources. The literature on the management of persistent pseudoaneurysm is limited. The decision to treat a persistent HPA that are found incidentally and stable in size needs further investigation.

The Prevalence of Nonsuicidal Self-Injury in Military Personnel: A Systematic Review and Meta-Analysis

Military service members and veterans (SMVs) are at risk for self-directed violence, including nonsuicidal self-injury (NSSI). While NSSI is an important construct worthy of independent study, it is understudied among SMVs and, when included in research, typically examined in the context of suicide risk. Consequently, lifetime prevalence rate estimates of NSSI among SMVs vary. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis estimated the average lifetime NSSI prevalence among SMVs and explored demographic and methodological factors that may account for observed variability. Based on a search of Ovid MEDLINE, Embase, PsycINFO, and Web of Science, 47 samples from 42 articles across five countries met inclusion criteria. Results revealed an average NSSI lifetime prevalence rate of 15.76% among SMVs. Significantly higher prevalence rates were observed among clinical (28.14%) versus community (11.28%) samples and studies using interviews to assess NSSI (23.56%) versus self-report (13.44%) or chart review (7.84%). Lifetime prevalence increased as publication year increased and decreased as sample size increased. In contrast to prior literature, prevalence rates were comparable between active-duty SMVs, and studies collecting data anonymously versus those that did not. Lifetime prevalence was not moderated by age, gender, race, country, primary research focus, quality of NSSI operationalization, or whether NSSI methods were assessed. Findings suggest NSSI is a pervasive problem among military personnel, particularly within clinical settings, highlighting the need for systematic assessment of this important but understudied clinical phenomenon among SMVs. Further research is necessary to elucidate additional risk factors for NSSI among SMVs, including trauma exposure.

Brachial Artery Injury Resulting From a Dog Bite in a Pediatric Patient: A Case Report

Pediatric trauma surgeons frequently encounter severe injuries from animal bites, with dog bites being especially prevalent in children, often leading to facial injuries. This paper details the case of a six-year-old male who suffered a dog bite resulting in a rare proximal right brachial artery injury. The bite caused deep lacerations and avulsion injuries, prompting admission to the trauma center, where nonpalpable right radial and ulnar pulses and arm weakness were observed. Surgical intervention, including wound exploration and brachial artery repair using a saphenous vein graft, successfully restored vascular perfusion. This case underscores the urgency of addressing pediatric dog bite injuries through timely exploration, thorough irrigation, and antibiotic prophylaxis, while also highlighting the need for further research on preventive education and clinical guidelines for assessing vascular injuries in such cases.

The association of military sexual assault and nonsuicidal self-injury in U.S. Gulf War-I era veterans

Military sexual assault (MSA) is a prevalent issue among military personnel that has been linked to adverse mental and physical health outcomes, including posttraumatic stress disorder (PTSD) and suicidal thoughts and behaviors. The present study sought to investigate the relationship between MSA and nonsuicidal self-injury (NSSI) in a national sample of Gulf War-I Era U.S. veterans. The study analyzed data from 1,153 Gulf War-I veterans collected through a cross-sectional survey that assessed demographic information, clinical outcomes, military background, and history of MSA and NSSI. MSA was found to be significantly associated with NSSI at the bivariate level (OR = 2.19, p < .001). Further, MSA remained significantly associated with NSSI (AOR = 2.50, p = .002) after controlling for relevant demographics and clinical outcomes. Veterans with a history of MSA were approximately two and half times more likely to engage in NSSI than veterans who had not experienced MSA. The present findings provide preliminary evidence linking MSA and NSSI. Further, the findings highlight the importance of assessing MSA and NSSI in veteran populations, particularly among those seeking treatment for PTSD.

Traditional Masculine Gender Role Norms and Nonsuicidal Self-Injury in Veterans

Reducing Veteran rates of suicide has long remained a top priority for the Veterans Health Administration, and as such, identifying correlates of suicidal behaviors is important to develop targeted interventions. Nonsuicidal self-injury (NSSI) has been identified as a robust predictor of suicide attempts; however, less is known about correlates of NSSI that may aid in upstream prevention efforts. Prior research suggests adherence to various traditional masculine gender role norms may be positively associated with NSSI. Thus, as the U.S. military is widely recognized for promoting and rewarding such norms, this study sought to build off previous research by examining the association between adherence to various masculine gender role norms and engagement in NSSI behaviors among a mixed-sex sample of U.S. Veterans (N = 124). Results showed the norm of emotional control was most strongly associated with lifetime engagement in NSSI behaviors (including the behavior of wall-object punching), whereas the norm of violence was associated with NSSI disorder. Interestingly, exploratory analyses indicated that these associations were primarily driven by women Veterans and sexual orientation status. Overall, the results highlight the importance of assessing for adherence to masculine gender role norms among all Veterans and speak to additional avenues for future research.

Correlates and clinical associations of military sexual assault in Gulf War era U.S. veterans: Findings from a national sample

Military sexual assault (MSA) is a prevalent issue among military personnel that can have direct implications on postmilitary mental health. Gulf War era U.S. veterans represent the first cohort in which women veterans were integrated into most aspects of military service except for combat. The present study sought to build on prior studies by identifying characteristics associated with the occurrence of MSA and clinical correlates of MSA and examining how these differ between men and women. This study analyzed cross-sectional survey data from a national sample of treatment-seeking Gulf War era veterans. Participants (N = 1,153) reported demographic information, clinical outcomes, military background, and history of MSA. MSA was more common among female veterans (n = 100, 41.3%) than male veterans (n = 32, 3.6%). The odds of experiencing MSA were approximately 19 times higher for female veterans relative to their male peers, OR = 18.92, p < .001. Moreover, as expected, MSA was robustly associated with probable current posttraumatic stress disorder, probable current depression, and past-year suicidal ideation in female veterans, whereas combat exposure was robustly associated with these sequelae in male veterans. The present findings confirm that a large proportion of female veterans from the Gulf War era experienced MSA and highlight the deleterious correlates of MSA on veterans' mental health. Sex differences of correlates of MSA and subsequent clinical associations are highlighted.

Qualitative analysis of participant experiences during an ecological momentary assessment study of nonsuicidal self-injury among veterans

Ecological momentary assessment (EMA) is a useful tool to investigate antecedents and consequences of nonsuicidal self-injury (NSSI), a robust predictor of Veteran suicide risk. Despite elucidating temporal changes among dynamic variables, EMA remains underutilized to study NSSI among veterans, perhaps due to concerns of safety and utility. The present study analyzed data collected from semi-structured interviews of veterans following a 28-day EMA study of NSSI, including benefits, challenges, and recommendations for improvement. Participants included 34 veterans endorsing NSSI history, most meeting criteria for NSSI Disorder. Qualitative analysis of de-identified transcripts used the rigorous and accelerated data reduction (RADaR) technique and thematic analysis. Findings revealed all veterans reported at least one emotional/social benefit to participation, including finding it therapeutic, gaining self-awareness/insight, and improved social functioning. Challenges and recommendations were primarily technology-related, including adjustment to device use. Many expressed interest in incorporation of clinical resources, use of personal devices/VA app, and ability to share responses with providers. Assessment frequency/content was never described as triggering suicidal/nonsuicidal urges and over half of participants noted urge/behavior reduction. Results support acceptability and safety of EMA for NSSI among veterans and potential clinical utility as a psychotherapy adjunct to promote self-awareness and NSSI reduction.

Affective states and nonsuicidal self-injury (NSSI): Results from an ecological momentary assessment study of veterans with NSSI disorder

BACKGROUND

The affective states most strongly associated with nonsuicidal self-injury (NSSI) remain poorly understood, particularly among veterans. This study used ecological momentary assessment (EMA) to examine relationships between affect ratings and NSSI urges and behaviors among veterans with NSSI disorder.

METHODS

Participants (N = 40) completed EMA entries via mobile phone for 28 days (3722 total entries). Entries included intensity ratings for five basic affective states, as well as NSSI urges and behaviors, during the past 4 hours.

RESULTS

Bivariate analyses indicated that each affect variable was significantly associated with both NSSI urges and behaviors. Angry/hostile and sad were most strongly associated with both NSSI urges and behaviors. A multivariate regression revealed that angry/hostile, disgusted with self, and happy (inversely related) were contemporaneously (within the same period) associated with NSSI behaviors, whereas all five basic affective states were contemporaneously associated with NSSI urges. In a lagged model, angry/hostile and sad were associated with subsequent NSSI urges but not behaviors.

CONCLUSIONS

Findings highlight the relevance of particular affective states to NSSI and the potential utility of targeting anger in treatments for NSSI among veterans. There is a need for future EMA research study to further investigate temporal relationships between these variables.

Closed-Loop Bowel Obstruction Years After an Open Abdominal Aortic Aneurysm Repair

A 68-year-old male has a significant past medical history of severe aortic stenosis, peripheral arterial disease, chronic kidney disease, and an abdominal aortic aneurysm treated with a bifurcated interposition aortobiiliac graft. He was admitted to the hospital for an elective one-vessel coronary artery bypass graft and placement of a bioprosthetic aortic valve. Postoperatively, he developed worsening abdominal pain, leukocytosis, and inability to tolerate nutrition by mouth. Computed tomography revealed moderately dilated loops of the small bowel with two transition points in the right lower quadrant. He was taken emergently to the operating room for an exploratory laparotomy, and a 28-cm necrotic jejunal loop was entrapped posterior to the right iliac segment of the graft. In a patient with an intra-abdominal synthetic vascular graft, a closed-loop bowel obstruction caused by entrapment by the vascular graft is exceptionally rare; however, it should be considered in the presence of bowel obstruction.

Nonsuicidal Self-Injury Disorder, Borderline Personality Disorder, and Lifetime History of Suicide Attempts among Male and Female Veterans with Mental Health Disorders

BACKGROUND

Expanding on research that has identified nonsuicidal self-injury (NSSI) as a strong predictor of suicide risk, the present study examined NSSI disorder (NSSID) and borderline personality disorder (BPD) as unique contributors to lifetime suicide attempts. To our knowledge, the present study represents the first exploration of these associations among veterans.

METHODS

Participants included 124 male (74%) and female (26%) veterans diagnosed with at least one mental health disorder. Posttraumatic stress disorder (93%) and major depression (86%) were the most common mental health diagnoses. Large proportions of the sample met criteria for NSSID (48%) and BPD (40%). Suicide attempts were reported by 28% of the sample. Chi-square tests determined the bivariate associations among NSSID, BPD, history of suicide attempts, and other variables. Significant diagnostic (i.e., MDD, BPD, and NSSID) and demographic (i.e., age) characteristics were included as covariates in a logistic regression model examining the associations of BPD and NSSID with suicide attempts.

RESULTS

BPD, Χ²=11.1, p<0.001, and NSSID, Χ²=13.9, p<0.001, were uniquely associated with suicide attempts. When all significant predictors were included in the final model, only NSSID emerged as a significant contributor to suicide attempts, OR = 4.9, p < 0.001.

LIMITATIONS

Causality cannot be determined from cross-sectional analyses.

CONCLUSION

These findings highlight NSSID as a powerful and unique correlate of suicide attempts among veterans, beyond the associations of established diagnostic risk factors. Improving our understanding of the relationship between NSSID and suicide risk has the potential to inform suicide prevention efforts and improve clinical outcomes among veterans.

Limb Salvage Resection of Massive Dedifferentiated Thigh Liposarcoma in a Patient Lost to Follow-Up

Dedifferentiated liposarcoma (DDL) is a rare soft tissue tumor that represents a non-lipogenic progression of well-differentiated liposarcoma (WDL). Unlike WDL, DDL has the propensity for metastasis and is associated with an increased incidence of local recurrence. For DDL of the extremities that is resectable with acceptable functional outcomes, treatment includes primary surgical resection with negative margins. Although rare due to advances in reconstructive techniques, amputation for DDL of the extremities should be considered in which appropriate tumor resection cannot be performed without adequate preservation of limb function. We present the clinical progression of a patient with a large DDL of the right thigh who was initially lost to follow-up, but ultimately underwent delayed definitive therapy with the intent for limb salvage. This case illustrates the importance of assessing neurovascular, osseous, and soft tissue involvement to properly predict and preserve limb function while achieving adequate tumor resection.

Post-traumatic symptom severity mediates the association between combat exposure and suicidal ideation in veterans

OBJECTIVE

Previous studies of military veterans have produced mixed findings regarding whether combat exposure is directly related to suicidal ideation or is indirectly related to suicidal ideation via its influence on other factors. The present study used a longitudinal design to test the hypothesis that post-traumatic stress disorder (PTSD) symptom severity mediates the effect of combat exposure on suicidal ideation in veterans.

METHOD

Participants included 319 post-9/11 veterans (83.4% male; 42.1% White/52.1% Black; Mage  = 39.7) assessed at baseline, 6, and 12 months. Structural equation modeling and bootstrapped confidence intervals were employed to examine the direct and indirect relationships between combat exposure, suicidal ideation, and PTSD symptom severity.

RESULTS

Results from the mediation model, in which demographic variables and non-combat trauma were included as covariates, revealed that the indirect effect of combat exposure on suicidal ideation via PTSD symptom severity was statistically significant, accounting for 64.1% of the covariance between combat exposure and suicidal ideation.

CONCLUSIONS

This study provides longitudinal evidence that the effects of combat exposure on suicidal ideation are mediated by PTSD symptom severity, suggesting the importance of targeting such symptoms in treatment to mitigate suicide risk among veterans with combat exposure.

Fournier's Gangrene in the Setting of Underlying Carcinoma: A Case Report and Review of the Literature

Most case series of Fournier's gangrene (FG) do not list malignancy as a cause; however, isolated cases with underlying malignancy of the soft tissue, genitourinary, and gastrointestinal systems have been described. After a review of recently published literature, 20 case reports and 15 case series or review articles included relevant information and were included in this literature review.

Malignancy is overlooked in 10% (2/20) of patients, resulting in a delayed diagnosis and initiation of cancer treatment. All patients with FG should have a thorough cancer history, digital rectal examination, appropriate local and systemic imaging, as well as tissue biopsies, to reduce the likelihood of a missed cancer diagnosis. Delay in management of the local malignancy may lead to persistence or recurrence of the infection and significantly worsens overall outcome and survival.

Sexual orientation, attraction and risk for deliberate self-harm: Findings from a nationally representative sample

To date, there has been limited investigation identifying predictors of deliberate self-harm (DSH) among sexual minority adults. The present study examined the likelihood of DSH by sexual minority status as measured by self-reported sexual identity and sexual attraction in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Among respondents who answered both the sexual identity and attraction items on the NESARC (N = 34,273), the link between sexual minority status and DSH was examined. Univariate analyses yielded greater risk of DSH for all sexual minority identities compared to heterosexual identity. Individuals with same-sex only attraction did not differ from those with different-sex only attraction. At the multivariate level, respondents reporting bisexual and unsure identity and bisexual attraction were at two to three times greater risk of DSH compared to their heterosexual/different-sex counterparts. Same-sex attracted and gay/lesbian individuals did not differ from different-sex attracted or heterosexual individuals in adjusted multivariate models. Findings from this nationally representative sample are consistent with previous research suggesting that sexual minority status is a risk factor for DSH. There is a vital need to incorporate varying measures of sexual minority status within research and in clinics, as well as to inquire about DSH among sexual minorities.

Development and Validation of Written Exam Items for the Agricultural Hazardous Occupations Orders (AgHOs) Certification Training Program

Research was conducted to develop and validate a pool of exam items that can be used to test the readiness of youth, ages 14-15 years, to be certified under the current federally mandated Agricultural Hazardous Occupations Orders (AgHOs). The AgHOs require training prior to employment in agricultural workplaces that the Secretary of Labor has determined are especially hazardous for youth within the prescribed age range. Under the current provisions of the AgHOs certification process, non-exempt youth seeking employment in agriculture are required to pass a written exam concentrating on safe work practices as partial satisfaction to receive certification of eligibility for employment to perform certain tasks. However, the regulations provide little guidance concerning the format of the exam, subject matter to be covered, degree of difficulty, or minimum passing score. As part of the USDA-sponsored Hazardous Occupations Safety Training in Agriculture (HOSTA) initiative, efforts have been made to develop consistent and evidence-based testing methods for disseminating the test protocols to instructors. The goal was to expand, enhance, and maintain the reliability of the exam item pool for the AgHOs certification process. Item development was based on the HOSTA-supported Gearing Up for Safety: Production Agriculture Safety Training for Youth curriculum. To ensure adequate item availability, the current item pool was expanded to include a minimum of two test items for each of the 157 cognitive-based core competencies developed as part of the Gearing Up curriculum design process. Administering 70-item exams that were generated from the item pool to 568 youth, ages 13-18 years, provided evidence of item validity. The result was a pool of 367 validated exam items.

Development and Validation of Written Exam Items for the Agricultural Hazardous Occupations Orders (AgHOs) Certification Training Program

Research was conducted to develop and validate a pool of exam items that can be used to test the readiness of youth, ages 14-15 years, to be certified under the current federally mandated Agricultural Hazardous Occupations Orders (AgHOs). The AgHOs require training prior to employment in agricultural workplaces that the Secretary of Labor has determined are especially hazardous for youth within the prescribed age range. Under the current provisions of the AgHOs certification process, non-exempt youth seeking employment in agriculture are required to pass a written exam concentrating on safe work practices as partial satisfaction to receive certification of eligibility for employment to perform certain tasks. However, the regulations provide little guidance concerning the format of the exam, subject matter to be covered, degree of difficulty, or minimum passing score. As part of the USDA-sponsored Hazardous Occupations Safety Training in Agriculture (HOSTA) initiative, efforts have been made to develop consistent and evidence-based testing methods for disseminating the test protocols to instructors. The goal was to expand, enhance, and maintain the reliability of the exam item pool for the AgHOs certification process. Item development was based on the HOSTA-supported Gearing Up for Safety: Production Agriculture Safety Training for Youth curriculum. To ensure adequate item availability, the current item pool was expanded to include a minimum of two test items for each of the 157 cognitive-based core competencies developed as part of the Gearing Up curriculum design process. Administering 70-item exams that were generated from the item pool to 568 youth, ages 13-18 years, provided evidence of item validity. The result was a pool of 367 validated exam items.

AIR synthetase in cowpea nodules: a single gene product targeted to two organelles?

A cDNA (VUpur5) encoding phosphoribosyl aminoimidazole (AIR) synthetase, the fifth enzyme of the de novo purine biosynthesis pathway has been isolated from a cowpea nodule cDNA library. It encodes a 388 amino acid protein with a predicted molecular mass of 40.4 kDa. The deduced amino acid sequence has significant homology with AIR synthetase from other organisms. AIR synthetase is present in both mitochondria and plastids of cowpea nodules. A signal sequence encoded by the VUpur5 cDNA has properties associated with plastid transit sequences but there is no consensus cleavage site as would be expected for a plastid targeted protein. Although the signal sequence does not have the structural features of a mitochondrial targeted protein, it has a mitochondrial cleavage site motif (RX/XS) close to the predicted N-terminus of the mature protein. Southern analysis suggests that AIR synthetase is encoded by a single gene raising questions as to how the product of this gene is targeted to the two organelles. VUpur5 is expressed at much higher levels in nodules compared to other cowpea tissues and the gene is active before nitrogen fixation begins. These results suggest that products of nitrogen fixation do not play a role in the initial induction of gene expression. VUpur5 was expressed in Escherichia coli and the recombinant protein used to raise antibodies. These antibodies recognize two forms of AIR synthetase which differ in molecular size. Both forms are present in mitochondria, although the larger protein is more abundant. Only the smaller protein was detected in plastids.

A new method of accurately identifying costs of individual patients in intensive care: the initial results

OBJECTIVES

To analyse the patient-related and non-patient-related costs of intensive care using an activity-based costing methodology.

DESIGN

A retrospective cost analysis of 68 patients admitted sequentially over a 10-week period.

SETTING

The Adult General Intensive Care Unit of the Royal Hallamshire Hospital, Sheffield.

RESULTS

The results showed large variations in the costs obtained for individual patients. The calculation of the costs for the initial period of stay showed a wide variation depending on whether the costs were determined per calendar day or per first 24-h period. Significant correlations of costs between the first 24 h of stay and the admitting Acute Physiology and Chronic Health II score (p < 0.004) and daily costs with the Therapeutic Intervention Scoring System scores (p < 0.0001) were found. The average daily patient-related cost of care was Pounds 592. Overhead costs were calculated at Pounds 560 per patient day, which made the total cost of a day's treatment in intensive care Pounds 1152.

CONCLUSIONS

The use of average costs or scoring systems to cost intensive care is limited, as these methods cannot determine actual resource usage in individual patients. The methodology described here allows all the resources used by an individual patient or group of patients to be identified and thus provides a valuable tool for economic evaluations of different treatment modalities.

The shine methodology--identifying telematic service opportunities for healthcare

The SHINE methodology has been developed to analyse the business needs of healthcare providers. It forms part of an overall SHINE framework that offers complete support from the development of an information technology strategy through to evaluating the implementation of telematic services. The five stages of the methodology are described together with its position in the overall framework. An example is presented showing the impact of applying the methodology to the entitlement assessment of medical cards and compares this approach with a more conventional approach.

Efficacy of psychotherapeutic counselling during 21-day ambulatory heroin detoxification

Structured, psychotherapeutic counselling during 21-day heroin detoxification was evaluated by randomly assigning a group of 25 heroin addicts to a detoxification treatment regimen with mandatory counselling by a therapist and 25 to a control group who received only standard detoxification without counselling. There was no significant difference between groups in the number who successfully detoxified as measured by conversion of morphine positive urine to morphine negative urine. The counselling intervention group did, however, improve the attendance of subjects while in detoxification treatment, and significantly more patients entered long-term treatment following detoxification. Maximal use of a counselor during 21-day heroin detoxification may best be realized by directing therapy toward engaging patients in long-term care.

Efficacy of psychotherapeutic counselling during 21-day ambulatory heroin detoxification

Structured, psychotherapeutic counselling during 21-day heroin detoxification was evaluated by randomly assigning a group of 25 heroin addicts to a detoxification treatment regimen with mandatory counselling by a therapist and 25 to a control group who received only standard detoxification without counselling. There was no significant difference between groups in the number who successfully detoxified as measured by conversion of morphine positive urine to morphine negative urine. The counselling intervention group did, however, improve the attendance of subjects while in detoxification treatment, and significantly more patients entered long-term treatment following detoxification. Maximal use of a counselor during 21-day heroin detoxification may best be realized by directing therapy toward engaging patients in long-term care.

Partial inactivation of cytochrome c oxidase by nonpolar mercurial reagents

Purified beef heart cytochrome c oxidase is inactivated to the extent of 35 to 50% by the nonpolar mercurial reagents mercuric chloride and ethylmercuric chloride. The inactivation is complete within 5 min. In titrations of activity, the plateau level of inactivation is attained at added ethylmercuric chloride:heme a ratios of about 1:1. Up to 3 mercury atoms/heme a are bound to the oxidase, although only the first of these affects its enzymatic activity. Incubation of the ethylmercury-modified oxidase with sulfhydryl compounds reverses the inactivation, with 2,3-dimercaptopropanol being most effective of the reagents tested. Spectrophotometric and polarographic assays of enzymatic activity show that Km values for the native and the ethylmercury-modified enzymes are practically indistinguishable, and that the partial inactivation observed for the latter is reflected exclusively in a lower value of Vmax compared to that of the native enzyme. Based on these results, we propose that ethylmercuric chloride reacts with a single crucial--SH group per heme a, and that electron transfer processes in the modified product are partially inhibited.