Chronic colonization with Pandoraea apista in cystic fibrosis patients determined by repetitive-element-sequence PCR

Pandoraea apista is recovered with increasing frequency from the lungs of patients with cystic fibrosis (CF) and may represent an emerging pathogen (I. M. Jorgensen et al., Pediatr. Pulmonol. 36:439-446, 2003). We identified two CF patients from our hospital whose sputum specimens were culture positive for P. apista over the course of several years. Repetitive-element-sequence PCR was employed to determine whether sequential isolates that were recovered from these patients represented a single clone and whether each patient had been chronically colonized with the same strain. Banding patterns generated with ERIC primers, REP primers, and BOX primers showed that individual patient isolates had a high degree of similarity (>97%) and were considered identical. However, only the banding patterns from the ERIC primers and BOX primers were able to show that the strains from patients I and II were unique (similarity indices of 79.8% and 70.0%, respectively). We concluded that all strains of P. apista from patient I were identical, as were all strains from patient II, establishing chronic colonization. Only two of the three methods employed indicate that the strains from the two patients are distinct. This implied that the organism was not transferred from one patient to the other, suggesting that the choice of methodology could generate misleading results when examining person-to-person transmission regarding this organism.

Variation among aging alcoholic patients in treatment

The authors compared demographic and clinical features of two groups of older patients with alcohol use disorders (n=205 and 124) selected before and after major program changes took place at a clinic designed specifically to treat aging alcoholic patients. Program changes (admission criteria, case-finding practices, treatments offered), significantly altered case-mix and treatment adherence. Results demonstrate variability among older alcoholic patients as well as the impact of program policies and practices on patient profiles and treatment responses.

Alcohol related dementia: proposed clinical criteria

Current diagnostic criteria for Alcohol Related Dementia (ARD) are based almost exclusively on clinical judgment. Moreover, there are no guidelines available to assist the clinician or the researcher in distinguishing Alcohol Related Dementia from other causes of dementia such as Alzheimer's Disease (AD). However, this distinction may have implications for the prognosis and treatment of patients. In this article, provisional diagnostic criteria for establishing a diagnosis of Alcohol Related Dementia are proposed for further study. The criteria are based on the available literature on the relationship between alcohol consumption and dementia and were modeled after existing diagnostic criteria for AD and Vascular Dementia. Validity of these criteria for distinguishing AD from ARD will require further study.

Outcome of nursing home care for residents with alcohol use disorders

OBJECTIVES

To describe the outcome of nursing home (NH) care for a previously established cohort of residents with active, inactive or no alcohol use disorder (AUD), and to examine demographic variables, health services utilization, mortality and drinking behaviors in this group.

DESIGN

Retrospective cohort study with participant interviews at NH admission and 3 years later.

SETTING

Urban Veterans Affairs (VA) Medical Center and Nursing Home Care Unit (NHCU).

PARTICIPANTS

Patients older than age 50 admitted consecutively to a VA NHCU between July 1991 and February 1993 who completed a structured interview, N = 117.

MAIN OUTCOME MEASURES

AUD as determined by DSM-III-R criteria. Demographics, health services utilization and mortality as abstracted from the VA medical record.

RESULTS

Health service utilization as measured by care episodes was not significantly different in the three groups (active, inactive and no AUD), but subjects with AUD had documented health services use related to alcoholism, including hospitalizations for alcohol-related illness, placements in long-term care facilities to control drinking and death from alcohol-related causes. The mean age at death was significantly younger for study participants with active or inactive AUD compared to those with no AUD: 67.7, 70.4 and 77.9 years, respectively (p < 0.004). Of the 21 participants with active AUD at NHCU entry, 11 resumed drinking after discharge and six still met criteria for active AUD 3 years later.

CONCLUSIONS

The subset of NHCU patients with active AUD continued to incur alcohol-related hospitalizations and institutionalizations following NHCU discharge and suffered early mortality relative to their peers. Effective models of care for this subset of patients should be sought.

Alcoholism and dementia

This article reviews epidemiological, neurological, cognitive, and imaging data on alcohol-induced dementia. Recent studies indicate that "heavy alcohol use" (variously defined) is a contributing factor in 21-24% of cases of dementia. Research difficulties include lack of positive diagnostic criteria, few post-mortem studies, and no accepted pathological mechanism. Sulcal widening and ventricular enlargement (occasionally reversible) are the strongest findings in patients with alcohol-induced dementia. There is evidence for peripheral neuropathy, ataxia, sparing of language, and improved prognosis when patients with alcohol-induced dementia are compared to other dements. Case examples, etiologic theories, and recommendations for research, training, and clinical practice are included.

Screening for alcohol use disorders in the nursing home

OBJECTIVES

To determine the prevalence of Alcohol Use Disorders (AUDs) among residents of a Veterans Affairs (VA) nursing home (NH) using DSM-III-R criteria for alcohol abuse and dependence, and to examine the demographic variables associated with AUDs among NH residents. A third objective was to assess the sensitivity, compared with DSM-III-R criteria, of three screening tests for AUDs in the NH: the CAGE, the MAST-G, and the two-question instrument developed by Cyr and Wartman.

DESIGN

A cross-sectional design, with DSM-III-R criteria determined by the alcohol module of the Diagnostic Interview Schedule (DIS) as the criterion standard.

PATIENTS

Patients older than age 50 admitted consecutively to a VA NH, n = 117.

MAIN OUTCOME MEASURES

Sensitivities, specificities, positive predictive values for the CAGE, MAST-G, and Cyr and Wartman Screening questionnaires; receiver operating characteristic (ROC) curves for the CAGE and MAST-G.

MAIN RESULTS

Forty-nine percent of study participants met DSM-III-R criteria for lifetime alcohol abuse or dependence (18% active, 31% inactive). The sensitivities and specificities of the three screening questionnaires were as follows: CAGE-82% and 90%; MAST-G-93% and 65%; Cyr and Wartman-70% and 92% respectively. The area under the ROC curve was 0.94 for the CAGE and 0.90 for the MAST-G.

CONCLUSIONS

The prevalence of lifetime alcohol abuse and dependence was high in this VA NH population. Both the CAGE and MAST-G are sensitive to AUDs in this setting. The areas under the ROC curves were not significantly different and indicate both tests discriminated well between NH residents with and without AUDs.

Principles of clinical medicine: an interdisciplinary integrated 2-year longitudinal course

In keeping with the Report of the Panel on the General Professional Education of the Physician (Association of American Medical Colleges 1984), Oregon Health Sciences University (OHSU) School of Medicine is in the midst of revising its curriculum. After a 4-year process, the Curriculum Committee mandated development of the Principles of Clinical Medicine course, a 2-year longitudinal course integrating input from both basic and clinical science departments. We describe the steps leading to the course's implementation, its administrative and organizational structure, the evaluation of student performance, teacher training, course curriculum, and the use of interdisciplinary teaching. This course embodies many of the changes called for in the AAMC Report and serves as a model for interdisciplinary education.

Factors affecting outpatient treatment compliance of older male problem drinkers

This study sought to identify predictors of outpatient treatment compliance in a cohort of 205 male problem drinkers, age 55 to 79 years. Patients agreed to attend a weekly outpatient therapy group designed for older persons and abstain from using alcohol for one year. Patients who were drinking-driving offenders, who had later onset of alcohol-related problems and/or whose spouses also participated in counseling were more likely than others to comply with outpatient requirements.

Late versus early onset problem drinking in older men

Age at onset of problem drinking was studied in 132 older men (age 60 years and older) admitted to a VA geriatric alcoholism outpatient treatment program. Demographics, alcohol history, self reported psychological status, special treatment, and treatment compliance variables were tested for association with onset age. Late onset (defined as onset of the first alcohol problem at or after age 60) was not uncommon, occurring in 15% of the sample (29% of patients age 65 or older). Compared to earlier onset cases, late onset alcohol problems were milder and more circumscribed, and were associated with less family alcoholism and greater psychological stability. Late onset patients were also more compliant with outpatient treatment requirements; however, treatment program variables were better predictors of compliance than onset age.

Aging and alcohol use disorders: diagnostic issues in the elderly

Alcohol use and use disorders in older people tend to be hidden and ignored by clinicians and scholars. Resulting misinformation about elderly alcohol problems can be found in such fundamental works as the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Yet, an extensive literature about the nature of geriatric alcohol problems has developed recently. This article reviews that literature, comments on current research at several North American centers, and offers some new information from the author's study of more than 300 older male alcoholics. Many findings remain to be replicated and further verified. Nonetheless, several coherent strands of information seem to be well substantiated: (a) problem drinking in the elderly constitutes a public health problem of moderate proportion, especially in men; (b) most signs predict increasing problem drinking in coming generations of elderly women and men; (c) many cases of geriatric alcoholism have late onset; (d) many geriatric cases are not properly identified; and (e) present screening and diagnostic methods for alcohol use disorders lack adequate validation for older persons.

Treatment compliance of older alcoholics: an elder-specific approach is superior to "mainstreaming"

A sample of 24 alcoholics (mean age, 58.8 years) treated in typical mixed-age outpatient groups, is compared to a sample of 25 alcoholics (mean age, 60.2 years) treated in special elderly peer groups. Patients treated in the special peer group program remained in treatment significantly longer and were more likely to complete treatment than those treated in mixed-age groups. These findings support the continued development and evaluation of elder-specific treatment approaches for older alcoholics.

Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders

Thirty-two patients with coexisting substance abuse and other psychiatric disorders were treated in a unique outpatient pilot program that used techniques drawn from both psychiatric and substance abuse treatment. Eleven patients remained in treatment for 3 or more months, and seven completed a year or more of treatment. Severity of associated psychiatric illness did not affect retention in treatment. Drug-abusing patients and those with personality disorders dropped out quickly; patients with a history of reliable outpatient treatment involvement tended to remain in treatment. Treatment retention was associated with reduced hospital utilization. The authors suggest guidelines for management of patients with coexisting substance abuse and other psychiatric disorders.

Posttraumatic stress disorder as an insanity defense: medicolegal quicksand

A growing awareness of posttraumatic stress disorder has led to recent use of the disorder as a legal defense against criminal responsibility for both violent and nonviolent crimes. Diagnosis of posttraumatic stress disorder is difficult because the symptoms are mostly subjective, often nonspecific, usually well publicized, and, therefore, relatively easy to imitate. Accurate psychiatric testimony in such cases requires diligent searching for collateral sources of information. The authors argue that the insanity defense is appropriate only in the rare instance that a dissociative episode related to posttraumatic stress disorder directly leads to criminal activity.

Early versus late onset alcoholism in older persons: preliminary findings

Systematic data comparing early onset (EO) versus late onset (LO) subgroups of older alcoholics is presented in this preliminary clinical report. Thirty-six older active problem drinkers, ages 53 to 76 years at the time of entry into a special outpatient treatment program, were assessed on selected demographic, psychological, alcohol history, and alcohol treatment compliance variables. There were 14 EOs (first alcohol problem prior to age 40 years) and 22 LOs (first problem after age 40). Compared to EOs, LOs reported less family alcoholism and greater current psychological stability. Treatment compliance in both groups was similarly high, compared to overall clinic norms.

The VA psychiatry service as a setting for residency education

The authors report data from a survey of chairmen of academic departments of psychiatry and chiefs of Veterans Administration (VA) psychiatry services concerning administrative relationships between academic psychiatry departments and VA psychiatry services and the education of psychiatry residents in VA settings. The extent and quality of relationships, the interdependence of academic departments and VA psychiatry services, factors important for good VA training, and advantages and disadvantages of using the VA for residency education are documented. The authors present their conclusions and recommendations for improving the quality of relationships between academic departments and VA psychiatry services and for strengthening psychiatric education in the VA setting.

Diagnosis of posttraumatic stress disorder in Viet Nam veterans: preliminary findings

Sixty-six Viet Nam veterans were evaluated for posttraumatic stress disorder. Several of the DSM-III criteria for the disorder, but no other clinical features, distinguished patients diagnosed as having the disorder from others. The findings tend to validate the DSM-III construct for this disorder.

Personality, prior drug use, and introspective experience during nitrous oxide intoxication

This report compares data on some personality characteristics and prior drug experiences of 60 volunteer young men with their subjective psychological responses while inhaling 40% nitrous oxide-oxygen mixtures for 20 min in a naturalistic laboratory setting. A rather specific trait-openness to "internal," reverie-type experiences-was very significantly related to a wide variety of drug responses, while several more general traits-including introversion and neuroticism-and openness to nonreverie mental experiences were unrelated to drug response. Prior illicit drug use was related only to mood on nitrous oxide, and not to other effects. Implications of the findings in the field of drug abuse are discussed.

Assessment of Viet Nam veterans for posttraumatic stress disorder in Veterans Administration disability claims

Since the Veterans Administration (VA) authorized compensation and other benefits for posttraumatic stress disorder, delayed type, in October 1980, the agency has received an increasingly large number of claims--mainly from Viet Nam veterans--for this disorder. An unprecedented challenge of the adequacy of psychiatric disability evaluation in the VA has thus been created. The authors describe efforts in one large program to meet this challenge and review 12 problems in the diagnostic process. Cooperation of all parties in claims transactions, thorough claimant assessment, reliance on DSM-III criteria and methods and consultation with examiners are essential principles for this work.

Effect of timing of cefuroxime dosage on its protection of rats against gentamicin nephrotoxicity

The neophrotoxic effect on rats of once daily treatment with 40 or 45 mg gentamicin/kg/day for ten days was substantially reduced by administration of 4 g cefuroxime/kg/day, either at the same time or eight hours later. This dosage of cefuroxime was protective when given for only two consecutive days starting on the first to third days of gentamicin treatment, but enhanced gentamicin nephrotoxocity when started on the sixth or subsequent days.

Toxicological studies on cefuroxime sodium

The intravenous LD50 of cefuroxime sodium for mice was 10.4 g/kg. The maximum dosage administered in other acute toxicity tests was well tolerated by mice (10 g/kg, subcutaneous), by rats (4 g/kg, intravenous, 5 g/kg, subcutaneous) and by cats, dogs and monkeys (2 g/kg, intramuscularly). Cefuroxime sodium was administered subcutaneously (s.c.) or intramuscularly (i.m.) for 3 months to rats (100, 300 or 900 mg/kg/day) followed by a recovery period, and also for 6 months to rats and dogs (50, 150 or 450 mg/kg/day) and for 1 month to monkeys (150 or 450 mg/kg/day). In all these tests there were no serious toxic effects. Minor haematological changes were attributable in part if not entirely to haemorrhage and tissue reaction at the site of injection of large doses. In rats large doses caused some increase in urine volume and electrolyte excretion, and slightly aggravated an age related nephropathy. Administration to rats intravenously (i.v.) for1 month of up to 400 mg/kg/day had no toxic effects. In reproduction studies on mice and rabbits there were no adverse effects on fertility, organogenesis or the rearing of young.

Current and emerging models of residential psychiatric treatment, with special reference to the California situation

The author reviews the steps that have led to the progressive deemphasis of psychiatric hospitalization in California and surveys the empirical basis for rejecting the usefulness of hospitalization. He discusses the four alternative residential models that have emerged in California as substitutes for state mental hospitals--general hospital psychiatric units, board and care homes, private psychiatric facilities available through vendor contracts, and convalescent hospitals. The author also touches briefly upon some important problems, including the possible fate of public general hospital psychiatric units, community mental health services, and the commitment law in California.