Substance use policy and practice in the COVID-19 pandemic: Learning from early pandemic responses through internationally comparative field data

The COVID-19 pandemic has created an unprecedented natural experiment in drug policy, treatment delivery, and harm reduction strategies by exposing wide variation in public health infrastructures and social safety nets around the world. Using qualitative data including ethnographic methods, questionnaires, and semi-structured interviews with people who use drugs (PWUD) and Delphi-method with experts from field sites spanning 13 different countries, this paper compares national responses to substance use during the first wave of the COVID-19 pandemic. Field data was collected by the Substance Use x COVID-19 (SU x COVID) Data Collaborative, an international network of social scientists, public health scientists, and community health practitioners convened to identify and contextualise health service delivery models and social protections that influence the health and wellbeing of PWUD during COVID-19. Findings suggest that countries with stronger social welfare systems pre-COVID introduced durable interventions targeting structural drivers of health. Countries with fragmented social service infrastructures implemented temporary initiatives for PWUD led by non-governmental organisations. The paper summarises the most successful early pandemic responses seen across countries and ends by calling for greater systemic investments in social protections for PWUD, diversion away from criminal-legal systems toward health interventions, and integrated harm reduction, treatment and recovery supports for PWUD.

Are psychotic-like experiences related to a discontinuation of cannabis consumption in young adults?

OBJECTIVE

To assess changes in cannabis use in young adults as a function of psychotic-like experiences.

METHOD

Participants were initially recruited at age 14 in high schools for the longitudinal IMAGEN study. All measures presented here were assessed at follow-ups at age 19 and at age 22, respectively. Perceived stress was only assessed once at age 22. Ever users of cannabis (N = 552) gave qualitative and quantitative information on cannabis use and psychotic-like experiences using the Community Assessment of Psychic Experiences (CAPE). Of those, nearly all n = 549 reported to have experienced at least one psychotic experience of any form at age 19.

RESULTS

Mean cannabis use increased from age 19 to 22 and age of first use of cannabis was positively associated with a change in cannabis use between the two time points. Change in cannabis use was not significantly associated with psychotic-like experiences at age 19 or 22. In exploratory analysis, we observed a positive association between perceived stress and the experience of psychotic experiences at age 22.

CONCLUSION

Age of first use of cannabis influenced trajectories of young cannabis users with later onset leading to higher increase, whereas the frequency of psychotic-like experiences was not associated with a change in cannabis use. The observed association between perceived stress and psychotic-like experiences at age 22 emphasizes the importance of stress experiences in developing psychosis independent of cannabis use.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Process evaluation of a cluster-randomised controlled trial of multi-component weight management programme in adults with intellectual disabilities and obesity

BACKGROUND

Providing effective weight management to adults with intellectual disabilities is necessary to challenge the high rates of obesity. The aim of this process evaluation was to explore the feasibility of conducting a full-scale clinical trial of the TAKE 5 multi-component weight management programme.

METHODS

The study was a 12-month pilot cluster-randomised controlled trial. Adults with intellectual disabilities and obesity were randomised to either TAKE 5, which included an energy deficit diet (EDD) or Waist Winners Too, based on health education principles. A mixed-methods process evaluation was conducted focussing on the reach, recruitment, fidelity, implementation, dose (delivered/received) and context.

RESULTS

The study successfully recruited adults with intellectual disabilities. Both weight management programmes were delivered with high fidelity and implemented as intended. Only one weight management programme, TAKE 5, demonstrated potential efficacy in reducing body weight and body composition. The effectiveness was largely attributed to the EDD and social support from carers.

CONCLUSIONS

The extensive process evaluation illustrated that a full-scale trial of a multi-component programme including an EDD is feasible and an acceptable approach to weight management for adults with intellectual disabilities and obesity.

Abstract P6-08-17: Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study

Background

Pregnancy associated breast cancer (PABC) is defined as breast cancer (BC) diagnosed during the gestational period (GP) or in the first year postpartum (PP). Despite its infrequent occurrence, the incidence of PABC appears to be rising due to the increasing propensity for women to delay childbirth. We have established the first combined prospective and retrospective registry study of PABC in Ireland to examine specific clinicopathological characteristics, treatments and maternal outcomes. We present the retrospective findings to date.

Methods

We performed a retrospective multicentre observational study of patients (pts) with PABC treated in the eight Irish cancer centres from August 2001 to March 2017. Data extracted included information on pt demographics, tumour biology, staging, treatment administered and maternal outcomes. Standard biostatistical methods were used for analysis.

Results

111 PABC patients were identified. Sixty pts (54%) were diagnosed during the GP and 51 (46%) within 1 year PP. Median age at diagnosis was 36 years (yrs). Table 1 illustrates baseline characteristics. Two thirds of pts were node positive and a similar proportion had grade 3 pathology. Seventy pts (63%) were estrogen receptor (ER) positive, 36 (32%) HER2 positive, 25 (22%) triple negative. Twenty-two pts (20%) were metastatic at presentation. Seven pts (6%) had a known BRCA 1/2 mutation. The median OS (overall survival) and DFS (disease free survival) for the entire cohort was 107.4 and 94.2 months respectively (resp). There was no survival difference between those diagnosed during the GP versus PP. 5 yr DFS and OS was 68.6% and 69.2% resp. This compares unfavourably to results reported by the National Cancer Registry of Ireland in a similar age-matched BC population between 2000-2012 where the 5 yr OS was 86.5%. Variables in our study associated with poorer outcomes included younger age, tumour size, node positivity and lack of estrogen expression.

Baseline characteristics PABC patients (n=11) %(n)Diagnosed in GP (n=60) %(n)Diagnosed 1yr PP (n=51) %(n)p valueDemographic    Age at diagnosis3636(25-49)36(21-44)0.31Stage    I-II54(60)55(33)53(27)0.85III23(26)23(14)23(12)1IV20(22)18(11)22(11)0.81Unknown3(3)3(2)2(1)1Pathology    Grade 366(74)70(42)63(32)0.43Node positive66(73)68(41)63(32)0.55ER+/HER2-41(45)38(23)43(22)0.69ER+/HER2+23(25)28(17)16(8)0.17ER-/HER2+14(16)17(10)12(6)0.59Triple negative22(25)17(10)29(15)0.11Surgery    Breast conservation23(26)25(15)21(11)0.82Mastectomy56(63)57(34)59(30)0.84Adjuavnt/Neoadjuvant treatment    Chemotherapy73(81)77(46)69(35)0.39Anthracycline68(55)78(36)54(19)0.03Taxane89(72)93(43)83(29)0.16Anti HER2 agent21(23)18(11)24(12)0.63Endocrine therapy64(52)63(29)66(23)0.84Radiotherapy79(64)74(34)86(30)0.85Relapse in Stage I-III    Local relapse15(13)12(6)18(7)0.55Distant relapse24(21)22(11)25(10)0.80

Conclusions

PABC patients may have a poorer outcome. Our study reported higher rates of triple negative and HER2 positive breast cancer which are associated with more aggressive biology. Prospective evaluation of clinicopathological features, pharmacokinetics of treatments selected and maternal and fetal outcomes is imperative in this distinct pt group.

Citation Format: Prior L, Teo M, Greally M, Ward C, O'Leary C, Aslam R, Darwish W, Ahmed N, Watson G, Kelly D, Kiely L, Hassan A, Gleeson J, Featherstone H, Lim M, Murray H, Gallagher D, Westrup J, Hennessy B, Leonard G, Grogan L, Breathnach O, Horgan A, Coate L, O'Mahony D, Coate L, O'Reilly S, Gupta R, Keane M, Duffy K, O'Connor M, Kennedy J, McCaffrey J, Higgins M, Kelly C, Carney D, Gullo G, Crown J, Walshe J. Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-17.

Harm Reduction From Below: On Sharing and Caring in Drug Use

This article focuses on how recreational drug users in the Netherlands and in online communities navigate the risks and reduce the harms they associate with psychoactive drug use. To do so, we examined the protective practices they invent, use, and share with their immediate peers and with larger drug experimenting communities online. The labor involved in protective practices and that which ultimately informs harm reduction from below follows three interrelated trajectories: (1) the handling and sharing of drugs to facilitate hassle-free drug use, (2) creating pleasant and friendly spaces that we highlight under the practices of drug use attunements, and (3) the seeking and sharing of information in practices to spread the good high. We focus not only on users’ concerns but also on how these concerns shape their approach to drugs, what young people do to navigate uncertainties, and how they reach out to and create different sources of knowledge to minimize adversities and to improve highs. Harm reduction from below, we argue, can best be seen in the practices of sharing around drug use and in the caring for the larger community of drug-using peers.

The effects of physical activity interventions on preventing weight gain and the effects on body composition in young adults with intellectual disabilities: systematic review and meta-analysis of randomized controlled trials

The aim of this study was to examine the literature on randomized controlled trials examining the efficacy of physical activity interventions to prevent weight gain and the effects on body composition in young adults with intellectual disabilities.A systematic search of Medline, Emabse, CINHAL, PsychINFO, Cochrane library and ERIC was conducted from 1946 to September 2014. Eligibility criteria included; randomized controlled trials of a physical activity intervention: objective measure of body weight and body composition; young adults (age range 16-24 years) with intellectual disabilities. Six studies met the eligibility criteria. The interventions varied in their prescription of physical activity including aerobic and strength-based activities. The mean duration of the interventions was 15.3 (range 10-21 weeks). There was no significant effect of physical activity interventions on body weight (weighted mean difference: -0.17 kg, 95% confidence interval, -1.04 kg to 0.72 kg) and body composition outcomes. The meta-analysis showed that physical activity interventions did not prevent weight gain in young adults with intellectual disabilities. Published studies are inadequate to form firm conclusions. Future longer term studies of interventions specifically designed for this population group are required to elucidate the effects of physical activity interventions on body composition and the prevention of weight gain in young adults with intellectual disabilities.

A reflective study on abortions in theatre

This article discusses the concept of conscientious objection in relation to surgical terminations of pregnancy. It explores a scrub nurse's duty of care not only to the patient but to themselves. It highlights the importance of being self-aware of one's moral and emotional attitude towards abortions in theatre. Doing so enables the nurse/ODP to practice professionally and autonomously, and to deliver the highest level of perioperative care whilst respecting their personal rights.

Management of arterial lines and blood sampling in intensive care: a threat to patient safety

In 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in our intensive care unit (ICU), we surveyed current practice in arterial line management and determined whether these recommendations had been adopted. We contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented - use of sodium chloride 0.9% as flush fluid, two-person checking of fluids before use - and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two-person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. Our survey provides evidence of continuing risk to patients.

Interrater variation in scoring radiological discrepancies

OBJECTIVE

Discrepancy meetings are an important aspect of clinical governance. The Royal College of Radiologists has published advice on how to conduct meetings, suggesting that discrepancies are scored using the scale: 0=no error, 1=minor error, 2=moderate error and 3=major error. We have noticed variation in scores attributed to individual cases by radiologists and have sought to quantify the variation in scoring at our meetings.

METHODS

The scores from six discrepancy meetings totalling 161 scored events were collected. The reliability of scoring was measured using Fleiss' kappa, which calculates the degree of agreement in classification.

RESULTS

The number of cases rated at the six meetings ranged from 18 to 31 (mean 27). The number of raters ranged from 11 to 16 (mean 14). Only cases where all the raters scored were included in the analysis. The Fleiss' kappa statistic ranged from 0.12 to 0.20, and mean kappa was 0.17 for the six meetings.

CONCLUSION

A kappa of 1.0 indicates perfect agreement above chance and 0.0 indicates agreement equal to chance. A rule of thumb is that a kappa ≥0.70 indicates adequate interrater agreement. Our mean result of 0.172 shows poor agreement between scorers. This could indicate a problem with the scoring system or may indicate a need for more formal training and agreement in how scores are applied.

ADVANCES IN KNOWLEDGE

Scoring of radiology discrepancies is highly subjective and shows poor interrater agreement.

Postterm pregnancy

Postterm pregnancy is a pregnancy that extends to 42 weeks of gestation or beyond. Fetal, neonatal and maternal complications associated with this condition have always been underestimated. It is not well understood why some women become postterm although in obesity, hormonal and genetic factors have been implicated. The management of postterm pregnancy constitutes a challenge to clinicians; knowing who to induce, who will respond to induction and who will require a caesarean section (CS). The current definition and management of postterm pregnancy have been challenged in several studies as the emerging evidence demonstrates that the incidence of complications associated with postterm pregnancy also increase prior to 42 weeks of gestation. For example the incidence of stillbirth increases from 39 weeks onwards with a sharp rise after 40 weeks of gestation. Induction of labour before 42 weeks of gestation has the potential to prevent these complications; however, both patients and clinicians alike are concerned about risks associated with induction of labour such as failure of induction and increases in CS rates. There is a strong body of evidence however that demonstrates that induction of labour at term and prior to 42 weeks of gestation (particularly between 40 & 42 weeks) is associated with a reduction in perinatal complications without an associated increase in CS rates. It seems therefore that a policy of induction of labour at 41 weeks in postterm women could be beneficial with potential improvement in perinatal outcome and a reduction in maternal complications.

A randomised study of peri-prosthetic bone density after cemented versus trabecular fixation of a polyethylene acetabular component

The ideal acetabular component is characterised by reliable, long-term fixation with physiological loading of bone and a low rate of wear. Trabecular metal is a porous construct of tantalum which promotes bony ingrowth, has a modulus of elasticity similar to that of cancellous bone, and should be an excellent material for fixation. Between 2004 and 2006, 55 patients were randomised to receive either a cemented polyethylene or a monobloc trabecular metal acetabular component with a polyethylene articular surface. We measured the peri-prosthetic bone density around the acetabular components for up to two years using dual-energy x-ray absorptiometry. We found evidence that the cemented acetabular component loaded the acetabular bone centromedially whereas the trabecular metal monobloc loaded the lateral rim and behaved like a hemispherical rigid metal component with regard to loading of the acetabular bone. We suspect that this was due to the peripheral titanium rim used for the mechanism of insertion.

Environment. Sustainable development of the agricultural bio-economy

A U.S. farm policy shift to joint production of commodities and ecological services will advance sustainable agriculture.

Foetal intrauterine growth restrictions with Helicobacter pylori infection

BACKGROUND

Helicobacter pylori infection has been associated with growth restriction in young children.

AIM

To determine whether there is an association between H. pylori infection and intrauterine growth restriction.

METHODS

Four hundred and forty-eight consecutive pregnant women (aged 15-44 years), attending for routine examinations in the third trimester, were enrolled. Clinical, demographic and previous obstetric data, as well as smoking history, were collected. At delivery, the weight, height, gender and status of the neonate were recorded; intrauterine growth restriction was defined if the birth weight was below the 10th percentile according to the gestational age for infants born in Australia.

RESULTS

Eighty-nine (20%) women were seropositive for H. pylori. The prevalence of H. pylori was significantly lower in Caucasians (17%) vs. non-Caucasians (42%, P < 0.0001). There were 34 (7.5%) cases of intrauterine growth restriction (7% Caucasians, 16% Asians, 12% Aborigines and 0% Pacific Islanders). Intrauterine growth restriction was more common in H. pylori-seropositive women than in H. pylori-seronegative women [13.5% vs. 6%; odds ratio (OR) = 2.41; 95% confidence interval (CI), 1.14-5.08; P = 0.018]. A multiple logistic regression model revealed that smoking (OR = 3.55; 95% CI, 1.62-7.79; P = 0.002), maternal height (OR = 0.48; 95% CI, 0.28-0.80; P = 0.005) and H. pylori seropositivity (OR = 2.59; 95% CI, 1.12-5.95; P = 0.025) were all independent risk factors for intrauterine growth restriction.

CONCLUSIONS

H. pylori infection in pregnant women may affect foetal intrauterine growth.

Evaluation of HIV-1 immunogen, an immunologic modifier, administered to patients infected with HIV having 300 to 549 x 10(6)/L CD4 cell counts: A randomized controlled trial

CONTEXT

Despite enormous improvements achieved through the use of antiretroviral therapies (ARTs), the risk for eventual human immunodeficiency virus (HIV) disease progression remains high. Agents that enhance the immunologic mechanism for viral recognition might reduce disease progression.

OBJECTIVE

To determine whether the addition of HIV-1 Immunogen would confer added clinical efficacy to that achievable by ARTs.

DESIGN AND SETTING

Multicenter, double-blind, placebo-controlled, randomized trial beginning March 1996 and ending May 1999 conducted at 77 centers in the United States providing primary care or referral care for persons infected with HIV.

PATIENTS

Adults infected with HIV who have baseline CD4 cell counts between 300 x 10(6)/L and 549 x 10(6)/L without prior acquired immunodeficiency syndrome-defining conditions receiving stable ART (or no therapy) were screened and 2527 were randomized.

INTERVENTIONS

Ten units of HIV-1 Immunogen, derived from a Zairian HIV isolate, inactivated and formulated with incomplete Freund adjuvant, was administered intramuscularly every 12 weeks. The placebo was incomplete Freund adjuvant. Changes in ARTs were allowed.

MAIN OUTCOME MEASURES

HIV progression-free survival; secondary end points included overall survival, changes in HIV RNA, CD4 cell counts, CD4 percentage, body weight, and immunogenicity.

RESULTS

The overall event rate was 1.8 per 100 person-years of follow-up. Fifty-three subjects developed clinical progression in each treatment group (relative risk [RR], 0.97; 95% confidence interval [CI], 0.66-1.42; P =.89). There were 19 and 23 deaths in the placebo and HIV-1 Immunogen groups, respectively (RR, 0.81; 95% CI, 0.44-1. 48; P =.49). There were no statistically significant differences between the groups with respect to changes in HIV RNA (P =.59), CD4 percentage (P =.63), or body weight (P =.89). Subjects in the HIV-1 Immunogen group had an increase in average CD4 cell count of approximately 10 x 10(6)/L greater than the placebo group (P =.02).

CONCLUSION

HIV-1 Immunogen with unrestricted ART failed to demonstrate an increase in HIV progression-free survival. JAMA. 2000;284:2193-2202.

Sickle cell disease in pregnancy

Homozygous sickle cell anaemia (Hb S) is the most common major haemoglobinopathy in the United States, occurring in approximately 1 in 626 African Americans. While haemoglobinopathies involving Hb S occur commonly in blacks of African descent, they are also found in people of Middle Eastern, East Indian and Mediterranean origin. It is an uncommon disease, especially in homozygous form, in Australia. We present the case of a woman in her third pregnancy, originally from Ghana, with HB F, and discuss the current issues in the management of sickle cell disease in pregnancy.

A randomized clinical trial comparing oral misoprostol with synthetic oxytocin or syntometrine in the third stage of labour

This is a multicentre, blocked, randomized trial to compare the efficacy of oral misoprostol 400 microg with current injectable uterotonic agents (oxytocin/ Syntometrine) used prophylactically in the third stage of labour. Main outcome measures were blood loss, use of a second uterotonic agent and difference in haemoglobin level from antepartum to postpartum. Data analysis from 863 women showed a statistically significant increase in both the mean blood loss (p < 0.001) and the rate of postpartum haemorrhage > 500 mL, (RR 2.72: 95% C1 1.73-4.27) in the misoprostol group compared to the oxytocin/Syntometrine group. The use of a second uterotonic agent was higher in the misoprostol group (RR 2.89: 95% Cl 2.00-4.18) as well as a greater decrease in postpartum haemoglobin (p = 0.015). Oral misoprostol 400 microg is significantly less effective than the traditional intramuscular uterotonic agents currently used and therefore cannot be considered as a viable option to these agents in the management of the third stage of labour.

Community Learning: The Reach for Health Nursing Program-Middle School Collaboration

Nursing faculty and students have a vital role to play in promoting adolescent health at the community level. However, few nursing education programs have developed programs which provide nursing students with the skills and hands-on experiences they need to work with adolescents in community settings. A successful model for integrating community-based adolescent health promotion into nursing education is described in this article. Developed by nursing faculty from Medgar Evers College Department of Nursing, teachers and staff from a large middle school in Brooklyn, New York serving economically disadvantaged Black and Hispanic youth, and Education Development Center, Inc., the Reach for Health (RFH) Nursing Program-Middle School Collaboration has two mutually reinforcing components: (a) classroom-based health instruction taught by teachers with assistance from nursing students and faculty, and (b) community youth service in which middle school students spend approximately 3 hours per week providing assistance in health-related facilities under the guidance of nursing faculty and student nurse mentors. As part of an evaluation study, the authors conducted focus groups with nursing students involved in this program and administered an identical survey before and after intervention to assess potential benefits of participation. Compared to a control group of nursing students, those who participated in the RFH program reported increased skills and comfort working in school and community settings and with young adolescents, their teachers, and their parents. An example of other benefits was a greater understanding of the health and developmental needs of adolescents. At the same time they provided a service to the community, nursing students gained the skills and experience needed to be effective in community health promotion efforts.

The effectiveness of the Reach for Health Community Youth Service learning program in reducing early and unprotected sex among urban middle school students

OBJECTIVES

This study evaluated the effectiveness of a community youth service (CYS) program in reducing sexual risk behaviors among African American and Latino urban young adolescents.

METHODS

A total of 1061 students at 2 urban middle schools were surveyed at baseline and 6-month follow-up. Students at one school were randomly assigned by classroom to receive either the Reach for Health CYS program or the Reach for Health classroom curriculum only. Students at the other school served as controls.

RESULTS

At follow-up. CYS participants reported significantly less recent sexual activity (P < .05) and scored lower on a sexual activity index than those in the control condition (P < .03). The greatest effect was among eighth graders, who received the most intensive service program (P < .03). The benefit of the curriculum-only intervention appeared greatest among students in special education classes.

CONCLUSIONS

Well-organized CYS that couples community involvement with classroom health instruction can have a positive impact on the sexual behaviors of young adolescents at risk for HIV, sexually transmitted diseases, and unintended pregnancy. This study also suggests the importance of including students in special education classes in health education programs.

Violence prevention and young adolescents' participation in community youth service

PURPOSE

To examine whether participation in a school-sponsored community youth service program reduces self-reported violent behaviors among young urban adolescents.

METHODS

A total of 972 seventh- and eighth-grade students at two large, urban, public middle schools were surveyed at baseline and at 6-month follow-up. One school was assigned to interventions and the other served as a control. All students at the intervention school received the Reach for Health classroom curriculum that included a 10-lesson unit focusing on violence prevention. In addition, approximately half the students were randomly assigned by classroom to participate in the Reach for Health Community Youth Service program (CYS). Under the guidance of teachers and community nurses, these students spent several hours each week providing service in local health care agencies. Regression analyses were used to assess the influence of treatment condition on violent behavior outcomes.

RESULTS

Comparing students in the curriculum-only and curriculum-plus-CYS interventions to the control group, there is a statistically significant interaction (p < .03) among grade, CYS participation, and violence at follow-up. Eighth-grade CYS students reported significantly less violence at follow-up than students in the control school, taking into account baseline level of risk behavior, gender, ethnicity, and social desirability (p < .04). There was no significant difference between controls and students in the curriculum-only condition. Comparing students in the CYS intervention to the curriculum-only condition within the intervention school, the grade by intervention interaction again is significant (p < .05). Eighth-grade CYS students-who received the broadest CYS experience-reported less violence at follow-up than their curriculum-only counterparts.

CONCLUSION

When delivered with sufficient intensity, school programs which couple community service with classroom health instruction can have a measurable impact on violent behaviors of a population of young adolescents at high risk for being both the perpetrators and victims of peer violence. Community service programs may be an effective supplement to curricular interventions and a valuable part of multicomponent violence prevention programs.

Oral health status of Canadian-born and immigrant adolescents in North York, Ontario

Studies from a number of countries, including Canada, have demonstrated that the oral health status of immigrants is worse than that of their native-born counterparts and that they make less use of dental services. To date, however, little information is available which documents changes in immigrant oral health following immigration. This paper reports the results of a study conducted in the City of North York, Ontario, that examined the oral health status of Canadian-born and immigrant adolescents aged 13 and 14 years. The former had better oral health than the latter on all parameters assessed and made more use of dental services. Within the immigrant population, there was a significant association between oral health and time since immigration. Those who had been in Canada 6 or more years were significantly healthier than those who had arrived within the preceding 2 years. While changing patterns of immigration may account for part of these differences, the data suggest that access to dental public health programs, delivered to students between the ages of 4 and 14 years, have been effective in improving the oral health of those born outside Canada. Since these programs cease at age 13 or 14 years, barriers to accessing the private dental care sector may mean that the residual inequities and inequalities evident in the data widen as these individuals age.

Ectopic pregnancy in lower segment uterine scar

A case of ectopic pregnancy in a lower uterine segment scar following previous Caesarean section is reported. A significant scar defect may result in deep implantation within the myometrium with the risk of persistent pain and bleeding followed inevitably by uterine rupture. In this report we discuss a number of management options. Except in the special situation of superficial implantation in a shallow scar defect where there is ultrasound evidence of continuity of the gestational sac with the uterine cavity we would strongly advise termination of the pregnancy.

Epidemiology of periodontal disease among older adults: a review

Although many epidemiological studies have been conducted concerning periodontal disease, the majority were not included in this review because of deficiencies in the measures used. Although it is increasingly common for studies in this field to measure periodontal disease using clinical attachment level, attachment loss or bone loss, the evidence pertaining to prevalence, incidence and risk in older adult populations is limited. Although it is the best indicator to date, characterizing periodontal disease by means of attachment loss has some limitations. Prevalence and incidence rates may vary according to the number of teeth and sites probed and bias and case misclassification may occur because of the healthy survivor effect. Moreover, prevalence data that document lifetime disease experience are of little use in planning for periodontal treatment needs. Problems with sampling or subject selection and idiosyncratic ways of reporting data also limit the quality of the evidence currently available. In order to standardize the collection of data on loss of attachment and to measure it as accurately as possible, Papapanou (63) recommends that studies use full-mouth periodontal examinations and the assessment of clinical attachment level at four sites on each remaining tooth. Given the inconsistencies in and problems with the methods used in the studies reviewed above, only broad conclusions can be drawn concerning periodontal disease in older adults. These confirm the conclusions reached in other reviews of the literature. While moderate levels of attachment loss are to be found in a high percentage of middle-aged and elderly subjects, severe loss is confined to a minority, albeit a substantial one. Severe loss is evident in only a few sites and, in general, affects only a small proportion of sites examined. Nevertheless, approximately one-fifth of older individuals have experienced more generalized severe loss; the rate is much higher in the oldest subjects and subjects from minority groups. Although not universal, severe disease is common in some older populations and some population subgroups. Studies using common approaches are needed to fully elucidate the extent to which disease experience varies across different populations. Similar conclusions can be drawn from prevalence studies measuring bone loss. These show that a minority of subjects accounted for most sites with advanced loss. Studies of incidence suggest that 50-75% of older adults experience additional loss of attachment of 2 or 3 mm or more at a minimum of one site over relatively short periods of time. Rates fall dramatically when more stringent case definitions are used. Moreover, relatively few sites examined show evidence of additional loss so that, although rates are high, extent and severity are low. More detailed analyses of incidence data, although few, indicate that new lesions are more common than progressing lesions, and the pattern of loss tends to support an episodic model of periodontal disease progression.

Prenatal ultrasound findings in a fetus diagnosed with Gaucher's disease (type 2) at birth

A 26-year-old woman with no significant history was found to have a fetus with hepatosplenomegaly and neurological abnormalities in utero on ultrasound. The baby was found to have a severe clinical manifestation of type 2 Gaucher's disease.

Pilot study of carotid surgery for acute stroke

BACKGROUND

Carotid endarterectomy is usually delayed for 2 months following an acute stroke, but the stroke may progress or a further stroke may occur. A randomized pilot study of urgent carotid surgery for acute stroke was undertaken to assess the feasibility of a definitive multicentre trial.

METHODS

Seven Manchester hospitals referred patients with acute stroke (less than 7 days previously), defined according to the Oxfordshire Community Stroke Project classification The carotid arteries were examined by portable continuous-wave Doppler ultrasonography. Patients with more than 50 per cent carotid stenosis on portable Doppler ultrasonography underwent colour duplex Doppler imaging. Patients with more than 70-99 per cent carotid stenosis were randomized to urgent carotid surgery or best medical care.

RESULTS

A total of 593 patients were assessed over 2 years. Of these, 414 had acute stroke, of whom 380 had probable cerebral infarction. Complete ipsilateral internal carotid artery occlusion was most common in patients with total anterior circulation infarcts (33 (28 per cent) of 117), whereas severe ipsilateral (70-99 per cent) stenosis was most common in partial anterior circulation infarcts (25 (20 per cent) of 128). Only 16 patients (one total and 15 partial anterior circulation infarcts) were fit enough for surgery and consented to randomization.

CONCLUSION

A definitive trial of urgent carotid surgery would need to screen large numbers of patients but could focus on patients with partial anterior circulation infarcts.

Patient satisfaction with a consultation at a cranio-facial pain unit

OBJECTIVE

Patient satisfaction is an important component of the evaluation of the quality of health care and has also been linked to therapeutic outcomes. The objective of this paper was to assess patient satisfaction with an initial consultation at a cranio-facial pain unit located in a large hospital in a major metropolitan centre.

DESIGN

A case series design was used. The study population consisted of new patients referred to the unit. One month before their initial appointment patients were mailed an oro-facial pain questionnaire. Immediately following the consultation they were mailed a satisfaction questionnaire which contained a modified version of the Dental Visit Satisfaction Scale.

RESULTS

Oro-facial pain data were collected from 121 patients and 78 of these returned a completed satisfaction questionnaire. While levels of satisfaction with the consultation were high overall, specific questions about consultation processes and outcomes revealed some sources of dissatisfaction. Just over half reported dissatisfaction with communications and one fifth were dissatisfied with outcomes in terms of diagnosis and treatment. Satisfaction with communication was the only dimension of the consultation process to be associated with satisfaction with outcomes, and satisfaction with outcomes was the main predictor of satisfaction overall.

CONCLUSIONS

Although the relationships between patients and practitioners at the unit were favourable, improvements in communications may be necessary if the full benefits of the consultation are to be realised. This can be difficult with this patient population whose conditions are complex and often poorly understood.

A concentrated and stable aerosol formulation of cationic lipid:DNA complexes giving high-level gene expression in mouse lung

Advances in gene therapy vectors and techniques hold promise for treatment of many inherited and acquired diseases. For lung indications, especially those involving the epithelium, delivery of the gene therapy vehicle ideally will involve the use of an aerosol. Aerosol delivery of transgenes using cationic lipids is currently limited by the ability to generate highly concentrated formulations of lipid:DNA complexes that are stable and retain their activity following aerosolization. We have examined many of the variables inherent in aerosolizing cationic lipid gene delivery vehicles and have devised a new formulation that incorporates small amounts of a polyethylene glycol-containing lipid. This formulation has allowed the preparation of concentrated dispersions of cationic lipid:plasmid DNA (pDNA) complexes (> 20 mM pDNA) at approximately 10-fold higher concentrations than previously reported. Most of the pDNA in these formulations was bound to the lipid component and thereby protected from nebulizer-induced shearing; the pDNA also maintained full biological activity both in vitro and in vivo. This new formulation thus represents a significant improvement over current methods to prepare concentrated, active cationic lipid gene delivery vectors, and provides a new tool with which to test gene transfer to the lung.

Optimization of formulations and conditions for the aerosol delivery of functional cationic lipid:DNA complexes

We have examined several variables inherent in aerosolizing cationic lipid:DNA complexes using a jet nebulizer and thereby have optimized the delivery of functional complexes. Maximal aerosol transfer efficiency of cationic lipid:pDNA complexes was quantitated and shown to require the presence of at least 25 mM NaCL as an excipient. This is possibly related to effects on the measured zeta potentials of the complex, which indicate that the complexes are more highly charged in solutions of physiological ionic strength than in solutions of low ionic strength. Inclusion of saline also resulted in retention of the starting lipid to plasmid DNA (pDNA) ratio following nebulization. These data were used to design in vitro aerosolization experiments with tissue culture cells that resulted in the identification of a cationic lipid:pDNA ratio of 0.75:1 (mol:mol) as being optimal for aerosolization. This formulation largely protected pDNA from shear degradation during nebulization and produced a respirable aerosol droplet size (1-3 microns). It was tested further in a mouse model and shown to result in the dose-dependent transfection of mouse lungs, generating the equivalent of several picograms of reporter gene activity per mouse lung. The results of these experiments have provided a set of optimal conditions for nebulizing cationic lipid:pDNA complexes that can be used as a starting point for the further evaluation of aerosol delivery of these nonviral gene delivery vectors in vivo.

Reasons for tooth extractions in dental practices in Ontario, Canada according to tooth type

In a study of tooth extractions in general dental practices in Ontario, Canada, 165 dental practitioners provided information on 6134 patients attending during a reference week. Of these, 11.6 per cent of patients had one or more permanent teeth extracted. Periodontal disease was given as the reason for 35.9 per cent of these extractions and caries for 28.9 per cent. Analysis by tooth type showed that third molars were the most common tooth type extracted. However, there were differences in the types of teeth extracted by age. Posterior teeth were most frequently lost by the younger age groups and anterior teeth by older subjects. There were also differences in the reasons for the loss of different tooth types. A comparison of these results with those of a similar study in Scotland suggests that age and tooth type does not account for the excess of extractions due to periodontal disease in this Canadian population. Differences in practice patterns and attitudes towards the retention of teeth may be contributing factors.

How do general practitioners manage patients at risk from stroke?

This study assessed by means of a postal questionnaire how general practitioners (GPs) manage patients at risk from stroke. Of the 640 GPs sent a questionnaire, 294 (46%) replied. In patients with a recent transient ischaemic attack or minor ischaemic stroke, 24% of responding GPs would not arrange any investigations. Sixty-one per cent refer under half of their patients for further investigation, although 99% of GPs would commence aspirin. Seventy-seven per cent of GPs were aware of the benefits of carotid surgery. For patients in atrial fibrillation, most GPs (77%) thought that warfarin reduced stroke rates, but only 20% would consider commencing warfarin, although 26% would commence aspirin. In hypertensive patients, the GPs' threshold for treatment ranged from 135 to 200mmHg systolic (median 160mmHg), and from 90 to 110mmHg diastolic (median 100mmHg). Most GPs (84%) would treat isolated systolic hypertension with a median threshold of 180mmHg (range 140-240mmHg). The results of this study suggest that some patients at risk from stroke may not receive optimal investigation and treatment in the community.