Implementing a pharmacist-integrated collaborative model of medication treatment for opioid use disorder in primary care: study design and methodological considerations

BACKGROUND

Pharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care.

METHODS

This study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site's capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber).

DISCUSSION

This study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients' access to MOUD and treatment outcomes.

TRIAL REGISTRATION

The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www.

CLINICALTRIALS

gov/study/NCT05310786?id=NCT05310786&rank=1.

Effects of a trauma‐informed mindful recovery program on comorbid pain, anxiety, and substance use during primary care buprenorphine treatment: A proof‐of‐concept study

BACKGROUND

A mindfulness-based intervention that reduces comorbid pain, anxiety, and substance use during office-based opioid treatment (OBOT) could enhance retention and prevent overdose. We conducted a pilot study of the Mindful Recovery OUD Care Continuum (M-ROCC), a 24-week trauma-informed program with a motivationally-sensitive curriculum.

METHODS

Patients prescribed buprenorphine (N = 18) enrolled in M-ROCC. We collected urine toxicology biweekly. At 0, 4, and 24 weeks, participants completed PROMIS-Pain, PROMIS-Anxiety, Mindfulness (FFMQ), Experiential Avoidance (BEAQ), Interoceptive Awareness (MAIA), and Self-Compassion (SCS-SF) scales. We estimated changes over time using mixed models. Participants completed qualitative interviews at 4 and 24 weeks.

RESULTS

Positive urine toxicology decreased over time for cocaine (β = -.266, p = .008) and benzodiazepines (β = -.208, p = .028). M-ROCC reduced PROMIS-Pain (Z = -2.29; p = .022), BEAQ (Z = -2.83; p = .0005), and increased FFMQ (Z = 3.51; p < .001), MAIA (Z = 3.40; p = .001), and SCS-SF (Z = 2.29; p = .022). Participants with co-morbid anxiety had decreased PROMIS-Anxiety (Z = -2.53; p = .012). Interviewed participants commonly used mindfulness practices for stress and anxiety (12/12, 100%), and to reduce pain catastrophizing and rumination (7/12, 58%).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This is the first study to report the effects of a 24-week mindfulness program during buprenorphine treatment on common comorbidities, including pain interference, anxiety, cocaine, and benzodiazepine use. The findings that M-ROCC is associated with reduced experiential avoidance, as well as increased interoceptive awareness and self-compassion, align with proposed mechanisms that are now extended to OUD treatment. Future larger randomized controlled trials are needed before effectiveness can be established and the role of these mechanisms can be confirmed.

"Today I Can Look in the Mirror and Like Myself": Effects of a Trauma-Informed Mindful Recovery Program on Self-Compassion

Background

Opioid-related deaths continue to rise. Psychological trauma is commonly comorbid with Opioid Use Disorder (OUD). Adverse childhood experiences can disrupt the development of emotion regulation, increasing risk of substance use. Self-compassion may reduce OUD risk and outcomes by facilitating emotion regulation, decreasing the toxicity of shame, and reducing internalized stigma that can hinder recovery. Mindfulness practice enhances self-compassion.

Methods

This study is part of a pilot (N = 18) of the Mindful Recovery OUD Care Continuum (M-ROCC) during buprenorphine office-based opioid treatment (OBOT). The present study was conducted to gain a deeper understanding of the intervention’s effects on self-compassion development, and to explore differential changes in self-compassion during the intervention among participants with varying intensity of trauma exposure measured by high levels of childhood adversity (defined by 4+ adverse childhood experiences (ACEs) at baseline). We conducted secondary analyses of a subset of qualitative interview data (N = 11 unique participants) collected for the pilot study (weeks 4 and 24, 14 total interviews) to elaborate upon changes in Self-Compassion Scale (SCS-SF) scores.

Results

In the primary pilot study, participants’ mean SCS-SF scores shifted significantly from baseline to week 24, β = 0.22, p = 0.028. This change is elaborated upon through interviews. Despite pervasive challenges to becoming more self-compassionate (e.g., trauma histories and substance use), participants reported increased compassionate self-responding and decreased uncompassionate self-responding. Mindfulness training was identified as the primary mechanism underlying the shift. Kindness to self and others and—to a lesser extent an increased sense of common humanity—were also identified as key to overall self-compassion. Compared to those in the lower ACEs group, participants in the higher ACEs group tended to have lower baseline self-compassion scores (d = 1.09, p = 0.055).

Conclusion

M-ROCC may increase self-compassion among patients with OUD during OBOT by increasing compassionate, and decreasing uncompassionate, self-responding. Patients with OUD with greater childhood adversity tended to have lower levels of self-compassion, which improved with M-ROCC. Future trials with larger samples are needed to confirm these potential outcomes, mechanisms, and differential impacts between ACEs subgroups.

Technology-Based Interventions in Substance Use Treatment to Promote Health Equity Among People Who Identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native: Protocol for a Scoping Review

BACKGROUND

Technology-based interventions (TBIs; ie, web-based and mobile interventions) have the potential to promote health equity in substance use treatment (SUTx) for underrepresented groups (people who identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native) by removing barriers and increasing access to culturally relevant effective treatments. However, technologies (emergent and more long-standing) may have unintended consequences that could perpetuate health care disparities among people who identify as a member of one of the underrepresented groups. Health care research, and SUTx research specifically, is infrequently conducted with people who identify with these groups as the main focus. Therefore, an improved understanding of the literature at the intersection of SUTx, TBIs, and underrepresented groups is warranted to avoid exacerbating inequities and to promote health equity.

OBJECTIVE

This study aims to explore peer-reviewed literature (January 2000-March 2021) that includes people who identify as a member of one of the underrepresented groups in SUTx research using TBIs. We further seek to explore whether this subset of research is race/ethnicity conscious (does the research consider members of underrepresented groups beyond their inclusion as study participants in the introduction, methods, results, or discussion).

METHODS

Five electronic databases (MEDLINE, Scopus, Cochrane Library, CINAHL, and PsycInfo) were searched to identify SUTx research using TBIs, and studies were screened for eligibility at the title/abstract and full-text levels. Studies were included if their sample comprised of people who identify as a member of one of the underrepresented groups at 50% or more when combined.

RESULTS

Title/abstract and full-text reviews were completed in 2021. These efforts netted a sample of 185 studies that appear to meet inclusionary criteria. Due to the uniqueness of tobacco relative to other substances in the SUTx space, as well as the large number of studies netted, we plan to separately publish a scoping review on tobacco-focused studies that meet all other criteria. Filtering for tobacco-focused studies (n=31) netted a final full-text sample for a main scoping review of 154 studies. The tobacco-focused scoping review manuscript is expected to be submitted for peer review in Spring 2022. The main scoping review data extraction and data validation to confirm the accuracy and consistency of data extraction across records was completed in March 2022. We expect to publish the main scoping review findings by the end of 2022.

CONCLUSIONS

Research is needed to increase our understanding of the range and nature of TBIs being used in SUTx research studies with members of underrepresented groups. The planned scoping review will highlight research at this intersection to promote health equity.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34508.

Compassion, stigma, and professionalism among emergency personnel responding to the opioid crisis: An exploratory study in New Hampshire, USA

OBJECTIVE

Drug overdoses are the leading cause of death in the United States for those under 50 years of age, and New Hampshire has been disproportionately affected, resulting in increased encounters with the emergency response system. The ensuing impact on emergency personnel has received little attention. The present study aimed to explore the experiences and perspectives of emergency personnel responding to the opioid crisis in NH, with a focus on their views toward people who use opioids.

METHODS

Thirty-six emergency personnel (emergency department clinicians, n = 18; emergency medical service providers, n = 6; firefighters, n = 6; and police officers, n = 6) in 6 New Hampshire counties were interviewed about their experiences responding to overdoses and their perspectives on individuals who use opioids. Directed content analysis was used to identify themes in the transcribed, semistructured interviews. The results were reviewed for consensus.

RESULTS

Several categories of themes were identified among emergency personnel's accounts of their overdose response experiences and perspectives, including varied degrees of compassion and stigma toward people who use opioids; associations between compassion or stigma and policy- and practice-related themes, such as prehospital emergency care and the role of emergency departments (EDs); and primarily among personnel expressing compassion, a sense of professional responsibility that outweighed personal biases.

CONCLUSIONS

Despite the magnitude of the ongoing opioid crisis, some emergency personnel in New Hampshire have sustained or increased their compassion for people who use opioids. Others' perspectives remain or have become increasingly stigmatizing. The associations of compassion and stigma with various policy- and practice-related themes warrant further investigation.

Feasibility and acceptability of mindful recovery opioid use care continuum (M-ROCC): A concurrent mixed methods study

As opioid overdose deaths increase, buprenorphine/naloxone (B/N) treatment is expanding, yet almost half of patients are not retained in B/N treatment. Mindfulness-based interventions (MBIs) designed to promote non-judgmental awareness of present moment experience may be complementary to B/N treatment and offer the potential to enhance retention by reducing substance use and addressing comorbid symptoms. In this pilot study, we examined the feasibility and acceptability of the Mindful Recovery OUD Care Continuum (M-ROCC), a trauma-informed, motivationally sensitive, 24-week MBI. Participants (N = 18) were adults with Opioid Use Disorder prescribed B/N. The study team conducted assessments of satisfaction, mindfulness levels, and home practice, as well as qualitative interviews at 4 and 24-weeks. M-ROCC was feasible in a sample with high rates of childhood trauma and comorbid psychiatric diagnoses with 89% of participants retained at 4-weeks and 72% at 24-weeks. Positive qualitative interview responses and a high rate of participants willing to refer a friend (100%) demonstrates program acceptability. Participant mindfulness increased from baseline to 24-weeks (β = 0.24, p = 0.001, d = 0.51), and increases were correlated with informal mindfulness practice frequency (r = 0.7, p < 0.01). Although limited by small sample size, this pilot study highlights the feasibility and acceptability of integrating MBIs into standard primary care Office-Based Opioid Treatment (OBOT) among a population with substantial trauma history.

Implementation of a New Hampshire community-initiated response to the opioid crisis: A mixed-methods process evaluation of Safe Station

BACKGROUND

New Hampshire (NH) ranked first for fentanyl- and all opioid-related overdose deaths per capita from 2014 to 2016 and third in 2017 with no rate reduction from the previous year relative to all other states in the US. In response to the opioid crisis in NH, Manchester Fire Department (MFD), the state's largest city fire department, launched the Safe Station program in 2016 in partnership with other community organizations. This community-based response to the crisis-described as a connection to recovery-focuses on reducing barriers to accessing resources for people with substance use and related problems. The study aim is to characterize the multi-organizational partnerships and workflow of the Safe Station model and identify key components that are engaging, effective, replicable, and sustainable.

METHODS

A mixed-methods design included: semi-structured qualitative interviews conducted with 110 stakeholders from six groups of community partners (Safe Station clients, MFD staff and leadership, and local emergency department, ambulance, and treatment partner staff); implementation and sustainability surveys (completed by MFD stakeholders); and ethnographic observations conducted at MFD. Qualitative data were content analyzed and coded using the Consolidated Framework for Implementation Research. Survey subscales were scored and evaluated to corroborate the qualitative findings.

RESULTS

Community partners identified key program characteristics including firefighter compassion, low-threshold access, and immediacy of service linkage. Implementation and sustainability survey data corroborate the qualitative interview and observation data in these areas. All participants agreed that community partnerships are key to the program's success. There were mixed evaluations of the quality of communication among the organizations.

CONCLUSION

Safe Station is a novel response to the opioid crisis in New Hampshire that offers immediate, non-judgmental access to services for persons with opioid use disorders requiring community-wide engagement and communication. Data convergence provides guidance to the sustainability and replicability of the program.

Evaluating the Effectiveness of a Web-Based Program (POP4Teens) to Prevent Prescription Opioid Misuse Among Adolescents: Randomized Controlled Trial

Background

Prescription opioid (PO) use is common among adolescents in the United States. Despite recent declines from unprecedented peaks in adolescent PO use (eg, in 2012-2013), there is seemingly paradoxical evidence that PO-related consequences (eg, opioid use disorder and overdoses) are increasing. These trends and their possible consequences emphasize the importance of prevention efforts targeting PO misuse. To our knowledge, we have developed the first interactive web-based program (POP4Teens [P4T]) focused specifically on the prevention of PO misuse among adolescents.

Objective

This study aimed to evaluate the effectiveness of P4T, a web-based program designed to prevent adolescent PO misuse, in comparison with JustThinkTwice (JTT), an active control website, on PO-related attitudes, knowledge, risk perception, and intentions to use.

Methods

We conducted a web-based randomized controlled trial in 2018. A total of 406 adolescents (aged 12-17 years) were randomly assigned to either P4T or JTT. The outcome variables were attitudes, knowledge, and risk perceptions associated with PO misuse, intentions to use POs, and program feedback. Data were collected at baseline and at 1, 3, and 6 months.

Results

Both programs resulted in significant and sustained improvements in intention to use POs, increased perceived risk, impacted expectancies consistent with prevention, and improved PO refusal skills. P4T produced significantly greater increases in PO-related knowledge than JTT did, and it was reportedly easier to use and more liked. Baseline scores for youth reporting past-year medical use of POs, friends who engage in nonmedical use of POs, and/or poor mental health underscored their at-risk status compared with youth from the other groups.

Conclusions

P4T positively impacted all study variables that are known to prevent PO misuse among teens. Moreover, its web-based nature simplifies the dissemination and implementation of this novel tool designed to help meet the challenges of the evolving national opioid crisis.

Trial Registration

ClinicalTrials.gov NCT02737696; https://clinicaltrials.gov/ct2/show/NCT02737696

"It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder

Background

Increasingly, treatment for opioid use disorder (OUD) is offered in integrated treatment models addressing both substance use and other health conditions within the same system. This often includes offering medications for OUD in general medical settings. It remains uncertain whether integrated OUD treatment models are preferred to non-integrated models, where treatment is provided within a distinct treatment system. This study aimed to explore preferences for integrated versus non-integrated treatment models among people with OUD and examine what factors may influence preferences.

Methods

This qualitative study recruited participants (n = 40) through Craigslist advertisements and flyers posted in treatment programs across the United States. Participants were 18 years of age or older and scored a two or higher on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool. Each participant completed a demographic survey and a telephone interview. The interviews were coded and content analyzed.

Results

While some participants preferred receiving OUD treatment from an integrated model in a general medical setting, the majority preferred non-integrated models. Some participants preferred integrated models in theory but expressed concerns about stigma and a lack of psychosocial services. Tradeoffs between integrated and non-integrated models were centered around patient values (desire for anonymity and personalization, fear of consequences), the characteristics of the provider and setting (convenience, perceived treatment effectiveness, access to services), and the patient-provider relationship (disclosure, trust, comfort, stigma).

Conclusions

Among this sample of primarily White adults, preferences for non-integrated versus integrated OUD treatment were mixed. Perceived benefits of integrated models included convenience, potential for treatment personalization, and opportunity to extend established relationships with medical providers. Recommendations to make integrated treatment more patient-centered include facilitating access to psychosocial services, educating patients on privacy, individualizing treatment, and prioritizing the patient-provider relationship. This sample included very few minorities and thus findings may not be fully generalizable to the larger population of persons with OUD. Nonetheless, results suggest a need for expansion of both OUD treatment in specialty and general medical settings to ensure access to preferred treatment for all.

Early implementation of screening for substance use in rural primary care: A rapid analytic qualitative study

Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

Understanding the increase in opioid overdoses in New Hampshire: A rapid epidemiologic assessment

BACKGROUND

New Hampshire (NH) has had among the highest rates of fentanyl-related overdose deaths per capita in the United States for several years in a row-more than three times the national average in 2016. This mixed-methods study investigated drug-using practices and perspectives of NH residents who use opioids to inform policy in tackling the overdose crisis.

METHODS

Seventy-six participants from six NH counties completed demographic surveys and semi-structured interviews focused on drug-using practices and perspectives, including use precursors, fentanyl-seeking behaviors, and experiences with overdose. Rigorous qualitative methods were used to analyze interview data including transcription, coding and content analysis. Descriptive statistics were calculated on quantitative survey data.

RESULTS

Eighty-four percent of interviewees had knowingly used fentanyl in their lifetime, 70 % reported overdosing at least once, and 42 % had sought a batch of drugs known to have caused an overdose. The majority stated most heroin available in NH was laced with fentanyl and acknowledged that variability across batches increased overdose risk. Participants reported high availability of fentanyl and limited access to prevention, treatment, and harm reduction programs. There was widespread support for expanding education campaigns for youth, increasing treatment availability, and implementing needle exchange programs.

CONCLUSIONS

A confluence of factors contribute to the NH opioid overdose crisis. Despite consensus that fentanyl is the primary cause of overdoses, individuals continue to use it and affirm limited availability of resources to address the problem. Policies targeting innovative prevention, harm reduction, and treatment efforts are needed to more effectively address the crisis.

Perceptions and preferences for long-acting injectable and implantable medications in comparison to short-acting medications for opioid use disorders

Aim

Treatment for opioid use disorders has recently evolved to include long-acting injectable and implantable formulations of medications for opioid use disorder (MOUD). Incorporating patient preferences into treatment for substance use disorders is associated with increased motivation and treatment satisfaction. This study sought to assess treatment preferences for long-acting injectable and implantable MOUD as compared to short-acting formulations among individuals with OUD.

Methods

We conducted qualitative, semi-structured telephone interviews with forty adults recruited from across the United States through Craigslist advertisements and flyers posted in treatment programs. Eligible participants scored a two or greater on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool, indicative of a past-year OUD. Interviews were transcribed, coded, and thematically analyzed.

Results

Twenty-four participants (60%) currently or previously had been prescribed MOUD. Sixteen participants (40%) expressed general opposition to MOUD, citing concerns that MOUD is purely financial gain for pharmaceutical companies and/or a "band aid" solution replacing one drug with another, rather than a path to abstinence. Some participants expressed personal preference for long-acting injectable (n = 16/40: 40%) and implantable formulations (n = 12/40: 30%) over short-acting formulations. About half of the participants were not willing to use injectables (n = 19/40: 48%) or implantables (n = 22/40: 55%), preferring short-acting formulations. Mixed evaluations of long- and short-acting MOUD focused on considerations of medication-related beliefs (privacy, concern over an embedded foreign body), the medication-related burden (convenience, provision of structure and support, medication administration, potential side effects), and medication-taking practices (potential for non-prescribed use, control over dosage, and duration of treatment).

Conclusions

Though many participants personally prefer short-acting to long-acting MOUD, some were open to including long-acting formulations in the range of options for those with OUD. Participants felt long-acting formulations may reduce medication-related burden and the risk of diversion. Conversely, participants expressed concern about invasive administration and loss of control over their treatment. Results suggest support for expanded access to a variety of formulations of MOUD. The use of shared decision making may also help patients select the formulation best aligned with their experiences, values, and treatment goals.

Screening for Substance Use in Rural Primary Care: a Qualitative Study of Providers and Patients

BACKGROUND

Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care.

OBJECTIVE

To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs).

DESIGN

As part of a multi-phase study implementing electronic health record-integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted.

PARTICIPANTS

Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine.

APPROACH

Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework.

KEY RESULTS

Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment.

CONCLUSIONS

Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.

Barriers to naloxone use and acceptance among opioid users, first responders, and emergency department providers in New Hampshire, USA

BACKGROUND

The United States is in the midst of a devastating opioid crisis, and the state of New Hampshire (NH) has been disproportionately impacted. Naloxone is an opioid overdose reversal medication that is critical for saving lives. This study was conducted to understand emergency responders' and opioid users' experiences with, and opinions about, naloxone use and distribution in NH.

METHODS

Semi-structured interviews were conducted with 76 opioid users and 36 emergency responders in six NH counties in 2016-2017. Interviews focused on respondents' experiences with opioid use and overdose. Interviews were transcribed, coded, and reviewed for consensus among coders. Directed content analysis was used to review high-level domains and identify subthemes.

RESULTS

Users and responders largely agreed that naloxone had become increasingly available in NH at the time of the study. Reported responder barriers to naloxone acceptance included perceptions that increased naloxone availability may enable riskier opioid use and fails to address the underlying causes of addiction. Reported opioid-user barriers included cost, legality, and lack of knowledge regarding distribution locations and indications for use.

CONCLUSION

Opioid users' and emergency responders' perceptions about naloxone may limit the optimal use of naloxone within the community. This study identifies opportunities to address misconceptions about naloxone and challenges in accessing naloxone, which may improve opioid overdose prevention strategies.

Web-Based Prescription Opioid Abuse Prevention for Adolescents: Program Development and Formative Evaluation

Background

The unprecedented number of youths engaged in nonmedical use of prescription opioids (POs), as well as the myriad negative consequences of such misuse, emphasizes the importance of prevention efforts targeting this public health crisis. Although there are several science-based, interactive drug abuse prevention programs focused on preventing the use of nonprescription drugs in youths, to our knowledge, there are no science-based interactive programs that focus on the prevention of PO abuse among adolescents.

Objective

The aim of this study was to develop and conduct a formative evaluation of a science-based interactive Web-based program focused on the prevention of PO abuse among adolescents aged 12 to 17 years (Pop4Teens). This study was conducted to prepare for a randomized controlled trial designed to evaluate the effectiveness of Pop4Teens compared with an active control website, JustThinkTwice.com (Drug Enforcement Administration), in impacting knowledge and attitudes about POs and perceptions of risk associated with the abuse of POs, as well as intentions to use and actual use of POs.

Methods

We conducted 6 focus groups with 30 youths (a mean of 5 per group: the eligibility being aged 12-19 years) along a continuum of exposure to POs (in treatment for opioid use disorder, in general treatment for other substance use disorder, prescribed an opioid, and opioid-naïve) and writing sessions with 30 youths in treatment for opioid use disorder (12-19 years) to inform the development of the Web-based prevention tool. Feasibility and acceptability of a prototype of the Web-based intervention were then assessed through individual feedback sessions with 57 youths (drawn from the same populations as the focus groups).

Results

We successfully completed the development of a Web-based PO abuse prevention program (Pop4Teens). Analyses of focus group transcripts informed the development of the program (eg, quiz content/format, script writing, and story editing). Selected writing session narratives anchored the planned scientific content by lending credibility and informing the development of compelling storylines intended to motivate the youth to engage with the program. Feedback session data indicated that the Web-based tool could be potentially useful and acceptable. In addition, feedback session participants demonstrated significant increases in their knowledge of key topics related to the prevention of PO abuse after the exposure to sections of the Web-based program.

Conclusions

The opioid crisis is predicted to get worse before it gets better. An effective response will likely require a multipronged strategy inclusive of effective evidence-based prevention programs acceptable to, and accessible by, a majority of youths.

Web-Based Cognitive Behavior Therapy for Chronic Pain Patients with Aberrant Drug-Related Behavior: Outcomes from a Randomized Controlled Trial

Objective

There is high unmet need for effective behavioral treatments for chronic pain patients at risk for or with demonstrated histories of opioid misuse. Despite growing evidence supporting technology-based delivery of self-management interventions for chronic pain, very few such programs target co-occurring chronic pain and aberrant drug-related behavior. This randomized controlled trial evaluated the effectiveness of a novel, web-based self-management intervention, grounded in cognitive behavior therapy, for chronic pain patients with aberrant drug-related behavior.

Methods

Opioid-treated chronic pain patients at a specialty pain practice who screened positive for aberrant drug-related behavior (N = 110) were randomized to receive treatment as usual plus the web-based program or treatment as usual alone. The primary outcomes of pain severity, pain interference, and aberrant drug-related behavior, and the secondary outcomes of pain catastrophizing and pain-related emergency department visits, were assessed during the 12-week intervention and at one and three months postintervention.

Results

Patients assigned to use the web-based program reported significantly greater reductions in aberrant drug-related behavior, pain catastrophizing, and pain-related emergency department visits-but not pain severity or pain interference-relative to those assigned to treatment as usual. The positive outcomes were observed during the 12-week intervention and for three months postintervention.

Conclusions

A web-based self-management program, when delivered in conjunction with standard specialty pain treatment, was effective in reducing chronic pain patients' aberrant drug-related behavior, pain catastrophizing, and emergency department visits for pain. Technology-based self-management tools may be a promising therapeutic approach for the vulnerable group of chronic pain patients who have problems managing their opioid medication.

A randomized controlled trial of buprenorphine taper duration among opioid-dependent adolescents and young adults

BACKGROUND AND AIMS

Few randomized controlled trials have evaluated buprenorphine treatment interventions for opioid-dependent youth. Consequently, optimal administration strategies for this cohort are unclear. Our aim was to evaluate the relative efficacy of two different buprenorphine taper lengths in promoting abstinence from illicit opioids and treatment retention among opioid-dependent youth.

DESIGN

A double-blind, placebo controlled, multicenter randomized controlled trial.

SETTING

Two hospital-based research clinics (Manhattan and Brooklyn) in New York City, USA from 2005 to 2010.

PARTICIPANTS

Volunteer sample of 53 primarily Caucasian participants between the ages of 16 and 24 (n = 11 under age 18) who met DSM-IV opioid dependence criteria.

INTERVENTION

Participants were assigned randomly to either a 28-day buprenorphine taper (n = 28) or 56-day buprenorphine taper (n = 25) via a parallel-groups design during a 63-day period. Both groups received behavioral counseling and opioid abstinence incentives. Both taper conditions had a minimum of 1 week of placebo dosing at the end of the taper.

MEASUREMENTS

The primary outcome was opioid abstinence measured as a percentage of scheduled urine toxicology tests documented to be negative for opioids. The secondary outcome was treatment retention, measured as number of days attended scheduled visits.

FINDINGS

Intent-to-treat analyses revealed that participants who received a 56-day buprenorphine taper had a significantly higher percentage of opioid-negative scheduled urine tests compared with participants who received a 28-day buprenorphine taper [35 versus 17%, P = 0.039; Cohen's d = 0.57, 95% confidence interval (CI) = 0.02, 1.13]. Participants who received a 56-day buprenorphine taper were retained in treatment significantly longer than participants who received a 28-day buprenorphine taper (37.5 versus 26.4 days, P = 0.027; Cohen's d = 0.63, 95% CI = 0.06, 1.19). Daily attendance requirement was associated with decreased abstinence and shorter retention compared with a two to three times weekly attendance requirement, independent of taper duration. Follow-up data were insufficient to report.

CONCLUSION

Longer (56-day) buprenorphine taper produces better opioid abstinence and retention outcomes than shorter (28-day) buprenorphine taper for opioid-dependent youth.

Patient vs provider reports of aberrant medication-taking behavior among opioid-treated patients with chronic pain who report misusing opioid medication

During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training.

Implementation of a Substance Use Recovery Support Mobile Phone App in Community Settings: Qualitative Study of Clinician and Staff Perspectives of Facilitators and Barriers

BACKGROUND

Research supports the effectiveness of technology-based treatment approaches for substance use disorders. These approaches have the potential to broaden the reach of evidence-based care. Yet, there is limited understanding of factors associated with implementation of technology-based care approaches in different service settings.

OBJECTIVES

In this study, we explored provider and staff perceptions of facilitators and barriers to implementation of a mobile phone substance use recovery support app with clients in 4 service settings.

METHODS

Interviews were conducted with leadership and provider stakeholders (N=12) from 4 agencies in the first year of an implementation trial of the mobile phone app. We used the Consolidated Framework for Implementation Research as the conceptual foundation for identifying facilitators and barriers to implementation.

RESULTS

Implementation process facilitators included careful planning of all aspects of implementation before launch, engaging a dedicated team to implement and foster motivation, working collaboratively with the app development team to address technical barriers and adapt the app to meet client and agency needs, and consistently reviewing app usage data to inform progress. Implementation support strategies included training all staff to promote organization awareness about the recovery support app and emphasize its priority as a clinical care tool, encouraging clients to try the technology before committing to use, scaling rollout to clients, setting clear expectations with clients about use of the app, and using peer coaches and consistent client-centered messaging to promote engagement. Perceived compatibility of the mobile phone app with agency and client needs and readiness to implement emerged as salient agency-level implementation facilitators. Facilitating characteristics of the recovery support app itself included evidence of its impact for recovery support, perceived relative advantage of the app over usual care, the ability to adapt the app to improve client use, and its ease of use. The mobile phone itself was a strong motivation for clients to opt in to use the app in settings that provided phones. App access was limited in settings that did not provide phones owing to lack of mobile phone ownership or incompatibility of the app with clients' mobile phones. Individual differences in technology literacy and provider beliefs about substance use care either facilitated or challenged implementation. Awareness of patient needs and resources facilitated implementation, whereas external policies and regulations regarding technology use introduced barriers to implementation.

CONCLUSIONS

The conceptually grounded facilitators and barriers identified in this study can guide systematic targeting of strategies to improve implementation of mobile phone interventions in community treatment settings. Results also inform the design of technology-based therapeutic tools. This study highlights directions for research with regard to implementation of technology-based behavioral health care approaches.

"This is not who I want to be:" experiences of opioid-dependent youth before, and during, combined buprenorphine and behavioral treatment

Novel, qualitative data were collected from youth in treatment for opioid dependence (2009-2010) regarding their experiences with opioid dependence and combined behavioral-pharmacological treatment. Urban youth participants were recruited from a larger randomized controlled trial examining the relative efficacy of two tapers of buprenorphine-naloxone, combined with behavioral treatment (ages 13-24 eligible). Twenty-two youth participated in 1- to 1.5-hour semi-structured interviews. A grounded theory approach guided the analysis. The results have the potential to inform the development of efficacious treatments for this growing, yet understudied, group of youth. Study implications and limitations are noted, and future research is prescribed.

Patients as collaborators: using focus groups and feedback sessions to develop an interactive, web-based self-management intervention for chronic pain

OBJECTIVES

To describe the development of an interactive, web-based self-management intervention for opioid-treated, chronic pain patients with aberrant drug-related behavior.

METHODS

Fifty-three chronic pain patients participated in either focus groups (N = 23) or individual feedback sessions (N = 30). Focus groups probed interest in and relevance of the planned content and structure of the program. Individual session participants reviewed draft program modules and provided feedback on acceptability, ease of use, and usefulness. Focus group transcripts were thematically analyzed, and summary statistics were performed on feedback data.

RESULTS

Focus group participants stressed the need for additional pain management strategies and emphasized themes consistent with planned program content related to: 1) ambivalence about opioids; 2) reciprocal relationships among cognition, mood, and pain; 3) importance of recognizing physical limitations; and 4) effectiveness of goal setting for increasing motivation and functioning. Participants also offered insights on: 5) the loss of identity due to chronic pain; and 6) the desire to connect with pain peers to share strategies for managing daily life. Feedback session data demonstrate that participants believed that a web-based tool would be potentially useful and acceptable, and that exposure to program sections significantly increased participants' knowledge of key topics related to self-management of chronic pain.

CONCLUSIONS

Results suggest the potential value of self-management for chronic pain patients and the potential acceptability of web-based delivery of intervention content. Focus group and feedback methodologies highlight the usefulness of including potential program users in intervention development.

The social production of substance abuse and HIV/HCV risk: an exploratory study of opioid-using immigrants from the former Soviet Union living in New York City

Background

Several former Soviet countries have witnessed the rapid emergence of major epidemics of injection drug use (IDU) and associated HIV/HCV, suggesting that immigrants from the former Soviet Union (FSU) may be at heightened risk for similar problems. This exploratory study examines substance use patterns among the understudied population of opioid-using FSU immigrants in the U.S., as well as social contextual factors that may increase these immigrants' susceptibility to opioid abuse and HIV/HCV infection.

Methods

In-depth interviews were conducted with 10 FSU immigrants living in New York City who initiated opioid use in adolescence or young adulthood, and with 6 drug treatment providers working with this population. Informed by a grounded theory approach, interview transcripts were inductively coded and analyzed to identify key themes.

Results

The "trauma" of the immigration/acculturation experience was emphasized by participants as playing a critical role in motivating opioid use. Interview data suggest that substance use patterns formed in the high-risk environment of the FSU may persist as behavioral norms within New York City FSU immigrant communities - including a predilection for heroin use among youth, a high prevalence of injection, and a tolerance for syringe sharing within substance-using peer networks. Multiple levels of social context may reproduce FSU immigrants' vulnerability to substance abuse and disease such as: peer-based interactional contexts in which participants typically used opioids; community workplace settings in which some participants were introduced to and obtained opioids; and cultural norms, with roots in Soviet-era social policies, stigmatizing substance abuse which may contribute to immigrants' reluctance to seek disease prevention and drug treatment services.

Conclusion

Several behavioral and contextual factors appear to increase FSU immigrants' risk for opioid abuse, IDU and infectious disease. Further research on opioid-using FSU immigrants is warranted and may help prevent increases in HIV/HCV prevalence from occurring within these communities.

Maximum-likelihood Estimation of 3D Event Position in Monolithic Scintillation Crystals: Experimental Results

We present a simple 3D event position-estimation method using raw list-mode acquisition and maximum-likelihood estimation in a modular gamma camera with a thick (25mm) monolithic scintillation crystal. This method involves measuring 2D calibration scans with a well-collimated 511 keV source and fitting each point to a simple depth-dependent light distribution model. Preliminary results show that angled collimated beams appear properly reconstructed.

Transgene expression produced by biolistic-mediated, site-specific gene integration is consistently inherited by the subsequent generations

The efficient production of stable transgenic plants is important for both crop improvement and functional genomics. Site-specific integration of foreign genes into a designated genomic position is an attractive tool for minimizing expression variability between transgenic lines. Here, we studied the utility of a Cre-mediated, site-specific integration approach, facilitated by particle bombardment, for streamlining the production of stable transgenic plants, using rice as a model species. Using this method, we generated 18 different transgenic lines containing a precise integration of a single copy of beta-glucuronidase gene (gusA) into a designated genomic location. Eleven of these lines contained no illegitimate integration in the background (single-copy lines), and seven contained illegitimate integrations in addition to the site-specific integration (multicopy lines). We monitored gusA expression in these lines up to three to four successive generations. Each of the single-copy lines expressed the gusA gene at consistent levels and nearly doubled the expression level in the homozygous state. In contrast, multicopy lines displayed expression variation and gene silencing. In about half of the multicopy lines, however, expression of the site-specific integration locus could be reactivated and stabilized on segregation of the illegitimate integrations, whereas, in the remaining half, expression could not be restored, as they contained genetically linked illegitimate integrations. This study demonstrates that biolistic-mediated, site-specific gene integration is an efficient and reliable tool for streamlining the production of stable transgenic plants.

Syndrome myxoma presenting as a pulmonary embolism: a case report

Although the incidence of primary cardiac tumors is approximately 0.28%, they are encountered in every age group and their clinical presentation usually resembles that of other cardiac or systemic diseases. The clinical symptoms of primary cardiac tumors are usually few until they are at an advanced critical stage making early diagnosis and treatment problematic. However, there is a subgroup of patients who may present with extracardiac systemic, endocrinologic or cutaneous manifestations and familiar inheritance allowing for early detection. This article describes the diagnosis and treatment of a young female who presented with an acute thromboembolic complication of an intracardiac myxoma.

The 4G/4G polymorphism of the hypofibrinolytic plasminogen activator inhibitor type 1 gene: an independent risk factor for serious pregnancy complications

The specific aim of the current study of 133 women with at least 1 pregnancy and measures of hypofibrinolytic and thrombophilic gene mutations was to determine retrospectively whether the mutations were associated with adverse pregnancy outcomes including prematurity, miscarriage, stillbirth, intrauterine growth retardation (IUGR), eclampsia, and abruptio placentae. Four gene mutations (factor V Leiden, methylenetetrahydrofolate reductase [MTHFR], prothrombin, and 4G/5G polymorphism of the plasminogen activator inhibitor type 1 [PAI-1] gene) were assessed by polymerase chain reaction (PCR). One hundred twenty-two women were genotyped for all 4 genes and divided into gene mutation (n = 68) and non-gene (n = 54) groups. The gene mutation group included those with at least 1 thrombophilic mutation (heterozygous for factor V Leiden, heterozygous for prothrombin, and homozygous for MTHFR), or hypofibrinolysis with homozygosity for the 4G polymorphism of the PAI-1 gene. The non-gene mutation group included those with no mutation for all 4 genes (wild-type normal) or who were wild-type normal for the prothrombin and factor V Leiden mutations and heterozygous for MTHFR and/or 4G/5G for the PAI-1 gene, neither heterozygosity associated with coagulation abnormalities. The 68 women with gene mutations, versus 54 in the non-gene mutation group, has more prematurity (10% v 4%, chi2 = 5.4, P = .021), more IUGR (3% v 0%, P = .035), and more total complications of pregnancy (37% v 21%, chi2 = 11.6, P = .001). The number of pregnancies (P = .0001) and 4G/4G polymorphism of the PAI-1 gene (P = .029) were positively associated with complications of pregnancy by stepwise logistic regression when the age, number of pregnancies, and all 4 gene mutations were the explanatory variables. Heritable hypofibrinolysis, mediated by 4G/4G homozygosity for the PAI-1 gene, is an independent significant, potentially reversible risk factor for pregnancy complications, probably acting through thrombotic induction of placental insufficiency.

Plasminogen activator inhibitor activity: an independent risk factor for the high miscarriage rate during pregnancy in women with polycystic ovary syndrome

In 41 women with at least one pregnancy drawn from a group of 149 (108 never-pregnant) women with polycystic ovary syndrome (PCOS), our specific aim was to determine whether hypofibrinolysis mediated by high plasminogen activator inhibitor activity (PAI-Fx) is an independent risk factor for miscarriage. The 41 women had 77 total pregnancies with 34 miscarriages (44%) and 42 live births (55%). There were 12 women with at least one pregnancy, at least one miscarriage, and no live births (16 pregnancies and 16 miscarriages). There were 15 women with at least one pregnancy, no miscarriages, and at least one live birth (25 pregnancies and 28 live births). Of 12 women with only miscarriages and no live births, 67% had PAI-Fx greater than 16.4 U/mL (normals' 95th percentile), versus 29% of 15 women with no miscarriages and all live births (chi2 = 3.8, P = .052). By stepwise logistic regression, the number of pregnancies (P = .0001) and PAI-Fx (P = .016) were significant positive explanatory variables for the number of miscarriages. Age, 4G/5G polymorphisms of the PAI gene, factor V Leiden, methylenetetrahydrofolate reductase (MTHFR) gene mutations, androstenedione, testosterone, sex hormone-binding globulin, the Quetelet index, and fasting serum insulin and glucose were not significant variables in the logistic regression model. In a separate stepwise logistic regression, three nonoverlapping groups of women (12 with > or = 1 pregnancy, > or = 1 miscarriage, and 0 live births, 10 with > or = 1 pregnancy, > or = 1 miscarriage, and > or = 1 live births, and 15 with > or = 1 pregnancy, 0 miscarriages, and > or = 1 live births) were the dependent variables. PAI-Fx was positively associated (P = .05) with the group with the worst pregnancy outcome (> or = 1 pregnancy, > or = 1 miscarriage, and 0 live births). The 41 women with PCOS and at least one pregnancy were more likely than healthy normal controls to have heterozygosity and homozygosity for the 4G/5G polymorphism of the PAI-1 gene (P = .028), but did not differ from normals for factor V Leiden (P > .10) or MTHFR (P > .09) mutations. PAI-Fx is a predominant independent significant positive reversible risk factor for miscarriage in women with PCOS.

Murine 86-kDa heat shock protein gene and promoter

The class of 90 kDa heat shock proteins (Hsp90) is among the most abundant heat shock proteins (Hsps) in eukaryotic cells. In vertebrates, Hsp90 is encoded by two distinct gene families giving rise to products of 84 and 86 kDa. In mice the expression of these two genes, hsp84 and hsp86, vary with respect to each other in responses to stress, and also in response to signals for growth and development. Therefore, as a step towards understanding the molecular basis for the differential regulation of these two genes, we have isolated and characterized genomic clones of the murine hsp86 gene and its 5' flanking region. The gene is composed of eleven exons interrupted by 10 introns. The 5' region contains consensus TATA, several stimulatory protein-1 binding site (SP1) elements as well as six consensus heat shock elements (HSE) 5' of the transcription start site. An 806 bp fragment of the 5' promoter region conferred constitutive expression upon a reporter gene and this expression was increased upon heat shock.

Correlation between hydrophobicity of short-chain aliphatic alcohols and their ability to alter plasma membrane integrity

The quantitative relationship between chemical structure and biological activity has received considerable attention in the fields of pharmacology and drug development. More recently, quantitative structure-activity relationships (QSARs) have been used for predicting chemical toxicity. It has been proposed that alcohols may elicit their toxic effects through hydrophobic interactions with the cellular membrane. The objective of this study was to evaluate the role of hydrophobicity in the loss of membrane integrity following acute exposure to short-chain aliphatic alcohols in rat liver epithelial cells in vitro. The series of alcohols studied included methanol, ethanol, 1-propanol, 1-butanol, 1-pentanol, 1-hexanol, 1-heptanol, 1-octanol, 2-butanol, 2-methyl-1-propanol, and 2-methyl-2-propanol. The lactate dehydrogenase (LDH) assay was used to quantify membrane integrity. The logarithm of the octanol/water partition coefficient (log P) was used to quantify hydrophobicity. LDH50 values, representing alcohol concentrations yielding a 50% increase in LDH release relative to untreated controls (i.e., mild disruption of membrane integrity), and EC50 values, representing alcohol concentrations yielding 50% of the maximal release of LDH (i.e., moderate disruption of LDH release), were experimentally determined for each alcohol. The LDH50 and EC50 values were then used to derive the QSAR relationship. The aqueous alcohol concentrations yielding LDH50 or EC50 values ranged from 8.9 x 10(-4) m (LDH50 for octanol) to 3.5 m (EC50 for methanol), and the log P of the alcohols ranged from -0.77 (methanol) to 3.00 (octanol). From these data, we have derived two QSAR equations describing the role of hydrophobicity in the release of LDH from rat liver epithelial cells following a 1-hr alcohol exposure. The QSAR equation for LDH50 values, log (1/LDH50) = 0.896 log P + 0.117 (n = 11, SD = 0.131), was nearly identical to the QSAR equation for EC50 values, log (1/EC50) = 0.893 log P + 0.101 (n = 11, SD = 0.133], suggesting that similar structure-activity relationships exist at both mild and moderate levels of membrane disruption. Our data indicate that an increase in LDH release was positively and linearly correlated with the hydrophobicity (r = 0.993). These data may help predict the potential biological effects of other, as yet untested, aliphatic alcohols and aliphatic alcohol-like compounds (e.g., anesthetics) on the plasma membrane.

Absence of germline mutations in exons 5-9 of the p53 gene in patients with Li-Fraumeni-like (SBLA) and familial adenomatous polyposis heritable cancer syndromes

Although acquired mutations in the human p53 gene occur in many tumor types, germline mutations are rare. An exception is the occurrence of germline p53 mutations in a fraction of families afflicted with the Li-Fraumeni syndrome (LFS). Previous studies from our laboratory demonstrated increased levels of wild type p53 protein in skin fibroblasts (SF) of patients from heritable cancer syndrome, including familial adenomatous polyposis (FAP), neurofibromatosis type 1 (NF1), and bilateral retinoblastoma (bRB) (Kopelovich and DeLeo, 1984,1986). Here, we further address the association between germline p53 alterations and genetic predisposition to cancer in the SBLA syndrome and in FAP. DNA sequencing and single-stranded conformational polymorphism analysis (SSCP) were utilized to screen for the presence of mutations within exons 5-9 of the p53 gene in SF and in benign tumors. Thus we observed no germline mutations in exons 5-9 of the p53 gene in SF from SBLA or FAP patients, including the Gardner variant. In addition, we observed no acquired mutations in exons 5-9 of the p53 gene in benign tumors from FAP patients. In conclusion, we found no association between germline p53 mutations and SBLA or FAP. How mechanisms that involve nonmutational activation of the p53 protein might affect genetic predisposition to cancer remains to be established.

Cloning and characterization of the promoter for murine 84-kDa heat-shock protein

The 90-kDa heat-shock (HS) proteins (HSP90) are members of the HSP family. Their synthesis is inducible by HS and a variety of stress signals. HSP90 is also abundant under normal physiological conditions and its synthesis can be regulated during growth and differentiation. Therefore, HSP90 is speculated to have important biological functions, in addition to its role in mediating stress responses. However, the mechanism(s) regulating hsp90 gene expression in nonstressed cells is poorly understood. As a prerequisite towards understanding the basis for hsp90 regulation, we have cloned and characterized the 5' flanking region of murine hsp84, one of two genes which code for HSP90 proteins. Full basal promoter activity of hsp84 was found to be associated with a 627-bp region immediately upstream from the transcription start point (tsp). Sequence analysis revealed several putative regulatory elements, including a HS element (HSE), an AP1-binding site (AP1), a cyclic AMP response element (CRE), and four stimulatory protein-1-binding sites (SP1). HS inducibility required the HSE which was bound by HS transcription factor-1(HSF-1) present in extracts prepared from cells exposed to HS. The HSE was not required for basal (non-HS) expression, but, interestingly, two protein-HSE complexes, devoid of HSF-1 and HSF-2, were formed under these conditions. The potential significance of these findings to the expression of hsp84 under normal physiological conditions is discussed.

Sign stimulus activates a peptidergic neural system controlling reproductive behavior in Aplysia

1. In the marine mollusk Aplysia, egg laying is a complex behavior that lasts for up to several hours. We used behavioral and electrophysiological methods to determine how egg laying occurs in groups of animals and how it is related to other aspects of reproductive behavior. 2. Prolonged contact with an existing egg mass by the lips and tentacles of an animal is a sign stimulus for release of egg-laying behavior and two other fixed action patterns in the same individual, mating as a female during egg laying and mating as a male after egg laying. 3. Prolonged contact with the egg mass initiated repetitive spike activity in bag cell neurons, which are part of a peptidergic neural system that modulates neuronal activity in the CNS for up to several hours. The sign stimulus thus activates the neuromodulatory system, which may serve as an innate releasing mechanism, and an associated internal drive, for control of the behavioral sequence.

Emergency department use of radiology services at a large urban teaching hospital

RATIONALE AND OBJECTIVES

Little research has explored the use of radiologic services by emergency departments and the factors that influence use. This study aimed to identify and characterize these factors.

METHODS

A total of 13,228 consecutive patient emergency charts from a large university emergency department were reviewed, and multiple parameters were entered into a database. The database was studied and statistical testing was done to identify significant parameters for patients who required imaging studies (X-ray group) and those who did not (non-X-ray group).

RESULTS

Factors such as age, diagnosis, urgency of illness, and illness severe enough to require hospitalization were statistically significant in determining the need for a radiologic evaluation in the emergency setting. When these factors were equalized for the X-ray and non-X-ray groups by multivariate linear regression analysis, male sex was also found to be statistically significant. Factors such as race and presence or absence of health insurance were not statistically influential on multivariate analysis.

CONCLUSIONS

Older age, diagnosis, and factors related to severity of illness affected the use of radiologic services in the emergency setting. Sex differences were also detected.

Serotypes of Streptococcus pneumoniae blood culture isolates from adults in Franklin County, Ohio

Isolates of Streptococcus pneumoniae in cultures of blood from 258 adults seen in 10 Franklin County, Ohio, hospitals from 1991 and 1992 were serotyped. Most strains (230 [89.2%]) belonged to serotypes that are included in the current pneumococcal vaccine. An additional 16 isolates (6.2%) were immunologically related to strains with serotypes that are included in the vaccine. Only 12 isolates (4.6%) were not covered by the vaccine. The rate of mortality from pneumococcal bacteremia in adults remains high (20%). While recent studies have documented the efficacy of the pneumococcal vaccine for preventing pneumococcal bacteremia (56 to 70%), use of the pneumococcal vaccine in susceptible patients by physicians remains low (19% in Franklin County). Additional efforts need to be expended to increase the use of the pneumococcal vaccine.

Two-component arterial blood pressure conditional response in rat

The objective of these experiments was to quantify the pattern of change in arterial blood pressure (BP) during a discriminative aversive classical conditioning paradigm in rat using a new "high resolution" computer analysis. Sprague-Dawley rats (n = 5) were restrained in a soft, conical cloth pouch and conditioned using a 6 sec. pulsed tone (CS+) followed by a 0.5 sec. tail shock; a steady tone, never followed by shock, served as a CS-. BP peaked at 16.4 +/- 6.5 mm Hg (mean +/- SD) above control at 1.5 +/- 0.1 sec. after onset of CS+. This "first component" ("C1") also occurred during CS- (12.1 +/- 3.8 mm Hg), although the magnitudes of the two were significantly (p < 0.05) different. Another group of rats (n = 8) was treated identically except the tones were 15 seconds long. The conditional BP response consisted of two components. C1 was reminiscent of that seen using the short tone: for CS+ a peak of 13.6 +/- 5.6 mm Hg at 1.5 sec. or, for CS-, of 10.0 +/- 4.3 at 1.3 sec. (p < 0.05). In CS+ trials BP peaked again ("C2," 7.4 +/- 2.5 mm Hg) at 8.3 +/- 1.2 sec. There was no statistically significant C2 for CS- trials, clearly demonstrating discrimination between tones. The unconditional BP response in both groups consisted of two large, closely spaced peaks in BP. Respiration was recorded in 3 additional rats. After shock delivery these subjects often showed a sudden shift between (1) a regular respiratory pattern with moderate chest excursion and (2) apneic episodes interspersed with single, deep breaths. This latter pattern was associated with large, low frequency fluctuations in BP. Continued development of the rat conditioning paradigm is especially warranted because of the ability to record sympathetic nerve activity in intact, awake subjects and the large number of readily available genetic strains, which model human pathological states.

Modification of alkylating agent induced cell kill by 2-nitroimidazoles in unclamped and clamped SC 9L tumors

Enhanced cell kill has been observed when experimental tumors were treated with alkylating agents in combination with 2-nitroimidazoles (2-NI). In this study, modification of the cell kill induced by cyclophosphamide (CY) and an analog, ifosfamide (IFO), by two radiation sensitizers, misonidazole (MISO) and etanidazole (SR-2508), was measured. Three important parameters were determined: (a) the necessity for hypoxic reduction of the 2-NI to achieve an increase in tumor cell kill, (b) the optimal timing for administration of the alkylating agents and the 2-NI, and (c) the degree of enhancement of the CY- and IFO-induced cell kill. The subcutaneous (sc) 9L tumor model in male Fisher 344 rats was used in these experiments, and the endpoint measured was clonogenic cell survival 18-20 hr after treatment. Under hypoxic conditions, MISO potentiated both CY- and IFO-induced cell kill with a sensitizer enhancement ratio of approximately 1.3 and 1.5, respectively, at the 10(-3) survival level. This enhancement was seen when CY was administered simultaneously or 1.5 hr prior to MISO administration. A similar enhancement of CY-induced cell kill was measured under hypoxic conditions when SR-2508 was used. Enhanced IFO-induced cell kill was measured under hypoxic conditions only when the IFO was given 1 hr before MISO administration. No enhancement of the IFO-induced cell kill was observed when SR-2508 was used instead of MISO. Increased normal tissue damage (i.e., hemorrhagic cystitis) was observed when the MISO was administered along with CY or IFO. Four conclusions can be drawn from these data. Metabolism of the 2-NI by hypoxic cells is necessary for potentiation of CY- or IFO-induced cell kill. Only MISO can potentiate the cell kill induced by IFO. The timing of administration of the alkylating agents and the 2-NI is a critical determinant of the extent of the cell kill obtained. Cell kill induced by IFO appears to be enhanced by MISO to a greater extent than the cell kill induced by CY.

Mapping of the mouse 86-kDa heat-shock protein expressed gene (Hsp86-1) on chromosome 12 and related genes on chromosomes 3, 4, 9, and 11

The HSP86 gene family in BALB/c, AKR/J, C58/J, and NFS/N inbred mice comprises an intron-containing expressed gene and, depending on the strain, two to four other HSP86-related members that are apparently processed pseudogenes. The expressed gene locus, Hsp86-1, was identified by its sequence identity with the mouse HSP86 cDNA coding region together with the presence of an intron at the same position as in the homologous human gene. Hsp86-1 was mapped 11.6 cM from the immunoglobulin heavy chain gene IgH on Chromosome 12 using an intersubspecies backcross. Two of the other loci that were common to all inbred strains tested, designated Hsp86-ps1 and Hsp86-ps2, were mapped to positions on Chromosomes 11 and 3, respectively. An HSP86-related locus specific to NFS/N and C58/J mice, designated Hsp86-ps3, was mapped on Chromosome 9. Also, an HSP86-related locus that was unique to NFS/N mice, designated Hsp86-ps4, was mapped to Chromosome 4.

Characterization of the mouse 84-kD heat shock protein gene family

The nucleotide sequence of a 6-kb region containing the gene for mouse 84-kD heat shock protein, HSP84, was determined. The hsp84 gene codes for a 5,500-base transcript and consists of 11 exons and 10 introns, ranging in length from 94 to 357 bp and 85 to 1,271 bp, respectively. One of the exons codes for a stretch of highly charged amino acids with two known phosphorylation sites. The presence of numerous introns in the hsp84 gene suggests that synthesis of the HSP84 protein would be precluded during severe heat shock, since such conditions interfere with splicing. The first intron, which is the largest, is located at the exact boundary between the 5'-untranslated region and the coding region and contains a sequence homologous to the heat shock element (HSE), an enhancer that is a characteristic feature of heat-inducible genes. A 71% homology was found between a 569-bp stretch within the first intron of the hsp84 gene, which includes the HSE-like sequence, and a portion of the first intron of the previously reported sequence of the human hsp89 beta gene. The promoter region of the hsp84 gene contained G + C-rich upstream sequences, potential binding sites for transcription factor Sp1, and a canonical TATA box. The hsp84 gene family includes at least six different hsp84-related pseudogenes, which arose about 2-3 million years ago.

Affinity purification, peptide analysis, and cDNA sequence of the mouse interferon gamma receptor

The receptor for mouse interferon gamma (IFN-gamma) was purified from detergent-solubilized plasma membranes of EL-4, a thymoma cell line which expresses a high number of receptors on its cell surface. The purification was carried out by immunoaffinity chromatography using an anti-receptor monoclonal antibody. The purified receptor was subjected to NH2-terminal sequence analysis as well as sequencing of endopeptidase-generated peptides. One of the peptides was found to be identical to a portion of the published amino acid sequence of the human IFN-gamma receptor deduced from cDNA. This information was utilized to construct a mixed-sequence oligodeoxynucleotide probe which permitted the isolation of a full-length cDNA clone coding for the mouse IFN-gamma receptor. The mouse IFN-gamma receptor cDNA is comprised of 105 base pairs of the 5'-untranslated region, an open reading frame coding for a 477-amino acid serine-rich protein having calculated Mr 52,276, and a 3'-untranslated region of 539 base pairs. The receptor is first synthesized as a pre-protein from which a 25-amino acid signal peptide is cleaved. The receptor contains a hydrophobic transmembrane portion near the center of the molecule. Northern blot analysis of various cell lines showed that each contained a single 2.0-kilobase mRNA. A direct correlation between the amount of IFN-gamma receptor mRNA and the level of receptor expressed on the cell surface was observed. The mouse and human IFN-gamma receptors are structurally similar, showing 51% over-all homology in amino acid sequence. Mouse IFN-gamma receptor cDNA when inserted in a mammalian shuttle vector and transfected into COS-7 monkey cells was able to direct the expression of specific binding activity for mouse IFN-gamma.

Estrogenic regulation of murine uterine 90-kilodalton heat shock protein gene expression

Murine uterine steady-state protein levels of the 90-kilodalton heat shock protein (HSP90) have been demonstrated recently to be increased by estrogen in a target tissue- and steroid-specific manner (C. Ramachandran, M.G. Catelli, W. Schneider, and G. Shyamala, Endocrinology 123:956-961, 1988). We now report that this regulation occurred with both the HSP86 and HSP84 forms of HSP90 as well as with the 94-kilodalton glucose-regulated protein. At the mRNA level, this response was greatest for HSP86 (15-fold). In contrast, estradiol had no significant effect on HSP70.

Transcriptional and translational analysis of the murine 84- and 86-kDa heat shock proteins

The mammalian 85-90-kDa heat shock protein(s) (hsp) have been shown to exist as two species of 84 and 86 kDa (Ullrich, S. J., Robinson, E. A., Law, L. W., Willingham, M., and Appella, E. (1986) Proc. Natl. Acad. Sci. U. S. A. 83, 3121-3125). Two cDNA clones corresponding to the two forms have been isolated which specifically hybridize to either a 2.85- or a 3.0-kilobase pair transcript corresponding to hsp 84 and 86, respectively (Moore, S. K., Kozak, C., Robinson, E. A., Ullrich, S. J., and Appella, E. (1987) Gene (Amst.) 56, 29-40, and this paper). The regulation of these hsp were examined in nontransformed NIH-3T3 and chemically transformed Meth A cells. The basal level of the hsp 84 mRNA transcript was approximately 2.5-fold greater than the hsp 86 transcript, with a corresponding ratio of hsp 84 to hsp 86 protein synthesis of approximately 2.5:1. After a transient heat shock (10 min, 44 degrees C), the rate of transcription of hsp 84 and 86 increased approximately 4.5- and approximately 7-fold, respectively, within 0.5 h and remained elevated for approximately 2 h. Northern blot analysis performed on NIH-3T3 and Meth A cells, during recovery from a transient heat shock, indicated that in both cells mRNA levels of both hsp increased rapidly, peaking at 5 h post-heat shock; hsp 84 and 86 transcripts were 1.5- and 2-fold higher than in non-heat-shocked cells, respectively. The increased rate of hsp synthesis after heat shock correlated with the increased levels of each transcript in both cell lines. In the transformed Meth A cells the basal mRNA, hsp synthesis, and steady state levels of each hsp in vitro were 2-3-fold higher than in the nontransformed NIH-3T3 cells. In Meth A tumors in vivo, the steady state level of hsp 84 was reduced compared to in vitro levels. Thus, in normal and in transformed murine cells, both hsp are heat-inducible, transcriptionally and translationally, with the transformed cells expressing higher levels of synthesis of both hsp 84 and 86. The data suggest that hsp 84 and 86 syntheses are primarily transcriptionally regulated.

Murine 86- and 84-kDa heat shock proteins, cDNA sequences, chromosome assignments, and evolutionary origins

The two forms of the approximately 90-kDa murine heat shock protein, referred to as HSP86 and HSP84, are coded for by separate but related genes. A full-length nucleotide sequence of the cDNA coding for HSP86 from a chemically induced tumor, Meth A, was determined. Sequences from a number of peptides from HSP86 were found to be in complete agreement with the nucleotide sequence. The HSP84 sequence from the same tumor was also completed. HSP86 and HSP84 are acidic polypeptides 733 and 724 amino acids long with calculated molecular weights of 84,796 and 83,290, respectively. The two proteins are 86% homologous. HSP86 was found to contain internal peptide repeats of Glu-Lys-Glu within a region of highly charged amino acid residues. The coding regions of the cDNAs were 76% homologous; however, this homology did not extend to the 5'- and 3'-untranslated regions. The 5'-untranslated region of hsp86 cDNA was considerably longer than that of hsp84 cDNA and, unlike that of hsp84, contained extraneous ATG triplets. Hsp86-related sequences were assigned to chromosomes 12, 11, and 3. An evolutionary tree constructed from HSP90-related protein sequences indicated that HSP86 and HSP84 were likely to have diverged more than 500 million years ago. The findings presented herein suggest that HSP86 and HSP84 may have different functions.

Human monocyte chemoattractant protein-1 (MCP-1). Full-length cDNA cloning, expression in mitogen-stimulated blood mononuclear leukocytes, and sequence similarity to mouse competence gene JE

The purpose of this work was to analyze cDNA encoding human monocyte chemoattractant protein-1 (MCP-1), previously isolated from glioma cell line culture fluid. Screening of a cDNA library from total poly(A) RNA of glioma cell line U-105MG yielded a clone that coded for the entire MCP-1. Nucleotide sequence analysis and comparison with the amino acid sequence of purified MCP-1 showed that the cDNA clone comprises a 53-nucleotide 5'-non-coding region, an open reading frame coding for a 99-residue protein of which the last 76 residues correspond exactly to pure MCP-1, and a 389-nucleotide 3'-untranslated region. The hydrophobicity of the first 23 residues is typical of a signal peptide. Southern blot analysis of human and animal genomic DNA showed that there is a single MCP-1 gene, which is conserved in several primates. MCP-1 mRNA was induced in human peripheral blood mononuclear leukocytes (PBMNLs) by PHA, LPS and IL-1, but not by IL-2, TNF, or IFN-gamma. Among proteins with similar sequences, the coding regions of MCP-1 and mouse JE show 68% identity. This suggest that MCP-1 is the human homologue of the mouse competence gene JE.

Cloning and nucleotide sequence of the murine hsp84 cDNA and chromosome assignment of related sequences

The nucleotide (nt) sequence of mouse 84-kDa heat shock protein (Hsp) cDNA has been determined using a combination of molecular cloning and oligodeoxynucleotide priming on poly(A) + RNA. The cDNA was 2.5 kb long, not including the poly(A) tail. It contained a 5' leader of about 94 nt that was G + C-rich, and a 243-nt 3'-untranslated region that was A + T-rich in the vicinity of the polyadenylation signal. Gene hsp84 codes for an acidic polypeptide of 724 amino acid (aa) residues. Mouse Hsp84 had 81% and 63% aa homology to Drosophila melanogaster Hsp82 and yeast Hsp90, respectively. The nucleotide sequence had 74% and 59% homology to Drosophila and yeast hsp sequences, respectively, in the coding regions of these genes. This homology did not extend to the 5' - and 3'-untranslated regions. Chromosomal analysis indicated that hsp84-related sequences are on at least three different chromosomes.

Nucleotide sequence of the argF regulatory region of Escherichia coli K-12

The deoxyribonucleotide sequence has been determined for the regulatory region of the arginine F gene (argF) of Escherichia coli K-12. The location of the argF coding region was deduced by comparison of the DNA sequence to the sequence predicted from the primary structure of the N-terminus of the argF gene product, the subunit of the "F" isoenzyme of ornithine transcarbamylase. Transcription of the argF gene was found to initiate at a position approx. 40 bp preceding the N-terminal codon for OTCase. Comparison of the region surrounding the origin of transcription with a computer-generated "model promoter sequence" revealed structural similarities between the two sequences, in particular, the promoter-associated stretches known as the "Pribnow box" and "minus 35 contact site". Another feature noted for the argF promoter region was its extreme abundance of A : T nucleotide pairs. In the region preceding the start site for argF translation, a sequence was observed to be complementary to the 3' end of the 16S RNA component of the E. coli ribosome. Both the length and the nucleotide sequence of the argF leader region indicate that the argF gene does not contain an attenuator proposed to exist in other operons concerned with amino acid biosynthesis.