Pain in alcohol use disorder: Evaluating effects of childhood trauma, perceived stress, and psychological comorbidity

The relationship between pain and alcohol use disorder (AUD) is complex and bidirectional. The current study examines risk factors for pain in a large comprehensively phenotyped sample including individuals from across the spectrum of alcohol use and misuse. Participants (n = 1101) were drawn from the National Institute on Alcohol Abuse and Alcoholism Natural History Protocol and included treatment-seeking AUD inpatients (AUD+Tx, n = 369), individuals with AUD not seeking treatment (AUD+, n = 161), and individuals without AUD (AUD-, n = 571). General linear models were utilized to test the effects of AUD status, history of childhood trauma exposure, perceived stress, and psychological comorbidity on daily percent time in pain, as well as change in daily percent time in pain across the inpatient stay in AUD+Tx individuals. Overall, 60.2% individuals reported any pain, with a significantly higher prevalence in the AUD+Tx group (82.1%) compared to the AUD+ (56.5%) and AUD- (47.1%) groups. Daily percent time in pain was also highest in the AUD+Tx group (30.2%) and was further increased in those with a history of childhood abuse and comorbid posttraumatic stress disorder (PTSD). Years of heavy drinking and craving were also associated with increased percent time in pain in the AUD+Tx group. Percent time in pain decreased following acute withdrawal in the AUD+Tx group but plateaued around 25% just prior to discharge. Individuals seeking inpatient treatment for AUD, especially those with a history of childhood trauma and/or comorbid PTSD, report greater percent time in pain compared to those not seeking treatment and those without AUD. The prolonged experience of pain in abstinent AUD inpatients after the resolution of acute withdrawal may signal the early stages of protracted withdrawal. Integrative treatments targeting pain and other symptoms of protracted withdrawal may be effective in improving overall function in people with severe AUD.

A realistic view of domestic violence screening in an emergency department

Sutherland Hospital is a district hospital serving The Sutherland Shire, a metropolitan area of Sydney. It has a population of approximately 220,000 which is predominantly Anglo-Saxon in ethnic origin. The Emergency Department provides emergency services for 30,000 new patients per annum. New South Wales Department of Health obtained Commonwealth funding from Partnerships Against Domestic Violence to pilot routine screening for domestic violence within 2 Area Health Services. One of the participating sites was the Emergency Department in South East Sydney Area Health Service. The aim was for nursing and medical staff to screen, for three months, all women sixteen years old and over. Information cards on state-wide domestic violence resources and referral flow charts were developed for the pilot. Staff undertook training and issues were addressed prior to the screening. In this article we will discuss the findings, including the rate of screening by the staff, disclosure rate of domestic violence, and action taken on disclosure. We will then proceed to explain the difficulties in undertaking screening within an Emergency Department, and make recommendations for those Emergency Departments interested in commencing screening.

Reversible impairment in monocyte major histocompatibility complex class II expression in malnourished surgical patients

BACKGROUND

Upregulation of major histocompatibility complex (MHC) class II antigen in response to the T-cell lymphokine interferon-gamma (IFN-gamma) is central to T cell-macrophage cooperation and immune homeostasis. We evaluated this property in malnourished surgical patients and assessed the impact of nutrition repletion with total parenteral nutrition (TPN).

METHODS

Sixty-two patients were studied: 37 malnourished and 25 controls. Whole blood was cultured with or without IFN-gamma (100 U mL-1), dual-labeled with anti-CD14 (monocyte) and anti-human leukocyte antigen-DR antibodies and analyzed by flow cytometry. Phagocytosis was measured by flow cytometry. In a second study, 10 severely malnourished patients received 5 days of TPN and MHC class II expression was measured at the end of this period.

RESULTS

The magnitude of the increase in monocyte MHC class II expression in response to IFN-gamma was significantly increased in the control group compared with the malnourished group (107% vs 53%; p < .05). This impairment directly correlated with severity of malnutrition, but did not correlate with age or disease type. The number of bacteria phagocytozed per cell was significantly decreased (p < .05) in the malnourished group. In study 2, there was a significant increase in MHC class II induction with IFN-gamma after short-term TPN (58% before vs 173% after, p < .001).

CONCLUSIONS

MHC class II induction in response to IFN-gamma is significantly impaired in malnourished patients, correlating with the severity of malnutrition. This defect is reversed by short-term TPN. These data identify the reversible loss of a key mechanism, fundamental to host defense, that may enhance the risk of infection in malnourished patients.

Cell-targeted 114Inm and drug (BCNU) combination therapy in a rat acute lymphoblastic leukaemia

A proportion of syngeneic female rats inoculated intramuscularly with a lethal T-cell lymphoblastic (Roser) leukaemia are cured by a single intraperitoneal injection of bischloroethylnitrosourea (BCNU) (Carmustine) (10 mg kg-1) given towards the end of the preleukaemic phase (day 7). Additional therapy on day 4, using intravenous leukaemia cells lethally labelled with the radionuclide 114Inm, enhanced the overall cure rate by 30%. The spleen is a major site of indium concentration from the targeting cells so that the continuous local radiation field appears to result in a substantial reduction of the body load of leukaemia cells in the enlarged spleen particularly, thus enhancing the curative potential of the drug. The results demonstrate in principle that in patients in remission a single dose of targeted radiotherapy in the spleen combined sequentially with an appropriate drug might provide considerable aid in eliminating a residual population of leukaemia cells.

Decreased interleukin-2 production in patients with gastrointestinal cancer

Mitogen-stimulated basal and maximal interleukin-2 production has been measured in 60 control subjects and 45 patients with gastrointestinal cancer (14 localized and 31 advanced). Peripheral blood T cell subsets in these subjects were also measured. In patients with advanced gastrointestinal cancer interleukin-2 production (mean +/- s.e.m. units/ml) is impaired when compared with that of control subjects (26.5 +/- 7 versus 61.1 +/- 9, P less than 0.0001) or patients with localized cancer (26.5 +/- 7 versus 59.4 +/- 13, P less than 0.02). This cannot be restored to normal by in vitro irradiation of the lymphocytes, suggesting that the impaired function is not due to IL-2 suppressor cells. Using monoclonal antibodies the percentages of T cell subsets were similar in all groups and we therefore conclude that the reduced production of IL-2 in these patients is due to deficient helper T cell function. These results provide a rational basis for the administration of exogenous IL-2 in the future management of patients with advanced gastrointestinal cancer.

Intensive treatment of pseudomonas chest infection in cystic fibrosis: a comparison of tobramycin and ticarcillin, and netilmicin and ticarcillin

Seventeen cystic fibrosis patients aged 3.1 years to 19.8 years had 30 courses of intensive treatment for relapse of their pseudomonas chest infection. The combination of netilmicin and ticarcillin was compared with tobramycin and ticarcillin in an open study. A significant subjective and objective improvement occurred in all patients. Pseudomonas was cleared temporarily from the sputum in 11 out of the 30 courses of treatment (37%). There was no significant difference between the netilmicin and tobramycin groups, nor evidence of sustained renal or ototoxicity. Intensive therapy of pseudomonas chest infection in cystic fibrosis patients is described in detail.

Choosing the right intravesical chemotherapeutic agent. Results of an in vitro monolayer cell culture assay

The use of a monolayer cell culture technique is described. Twenty-four superficial bladder tumours have been tested against Thiotepa, Adriamycin and Mitomycin C. Cultures were set up in parallel for a clonogenic assay after the method of Salmon. In the monolayer all 24 tumours grew; 21 showed a greater than 50% inhibition to Mitomycin, 13 to Adriamycin and 6 to Thiotepa. In the clonogenic assays, only 12 grew satisfactorily. It is concluded that this monolayer assay gives a reasonable prediction of the sensitivities of the commonly used intravesical agents.

Changes in human natural killer activity early and late ater renal transplantation using conventional immunosuppression

The natural killer (NK) cell activity of human peripheral blood lymphocytes falls following major surgical procedures including renal transplantation but in non-immunosuppressed individuals returns to normal levels within the first 72 hr after operation. In renal allograft recipients, if this early postoperative fall is excluded from the analysis, NK cell function appears to follow changes in allograft function, suggesting that in vivo, as has been reported in vitro, NK activity is generated during activation of the alloreactive process. In an additional group of patients whose grafts were functioning for between 3 and 102 months after cadaveric renal transplantation using conventional immunosuppression, NK function was depressed in comparison with that of control subjects. However, some patients who were more than 48 months post-transplant had normal NK cell activity. Collectively, these results suggest that NK cell function may recover despite the continued administration of conventional immunosuppressive agents.