A randomized control trial of a combined community health worker and re-entry intervention for people with HIV recently released from jail who use substances

INTRODUCTION

People with human immunodeficiency virus (HIV; PWH) who use substances are disproportionately involved in the criminal justice system. While HIV viral suppression typically improves during incarceration, these gains are frequently lost after release. We evaluated the impact of a combined intervention (formerly incarcerated community health workers [CHW] plus a re-entry organization; CHW+) on postrelease HIV- and substance use-related outcomes.

METHODS

We conducted a pilot randomized controlled trial of a CHW+ for PWH who use substances, within 30 days of release from a large southern, urban jail. Between February 2019 and August 2021, participants were recruited, enrolled, and randomized to treatment as usual (TAU; passive referral to care) or CHW+. Follow up study visits occurred at 3, 6, and 12 months. The primary outcome was HIV VL at 6 months; secondary outcomes included 6-month urinary toxicology and high-risk substance use at 12 months.

RESULTS

A total of 31 participants were enrolled who were primarily male (n = 24; 77 %), Black (n = 22; 71 %), unemployed (n = 23; 74.2 %), had unstable housing (n = 18; 58 %), had food insecurity (n = 14; 45 %), and reported their drug of choice was stimulants (n = 24; 77 %). The study identified no significant difference in HIV VL suppression at 6 months (20 % v. 37 %; [CHW+ v. TAU], p = 0.61). We observed improved substance use outcomes in CHW+ v. TAU, including fewer positive urinary toxicology screens for stimulants (40 % v. 100 %; p = 0.01) and a trend toward less high-risk substance use (30 % v. 43 %). The CHW+ group met more basic needs, such as food security [+32 % v. +11 %], housing security [+52 % v. -7 %] and full-time employment [+20 % v. +5 %] compared to TAU.

CONCLUSIONS

PWH who use substances assigned to a combined intervention of CHW+ after jail release did not achieve higher rates of HIV VL suppression than TAU; however, they had improved substance use outcomes and met more basic subsistence needs. Results highlight the potential of culturally informed interventions to address the competing needs of PWH who use substances after release from jail and call for further development of innovative solutions to successfully bridge to HIV care in the community.

For Health Equity, We Must End Mass Incarceration

This Viewpoint discusses the health harms to individuals and communities because of mass incarceration in the US and proposes interventions to ensure health equity for all individuals.

The Reentry Health Care Hub: Creating a California-Based Referral System to Link Chronically Ill People Leaving Prison to Primary Care

People released from prison experience high health needs and face barriers to health care in the community. During the COVID-19 pandemic, people released early from California state prisons to under-resourced communities. Historically, there has been minimal care coordination between prisons and community primary care. The Transitions Clinic Network (TCN), a community-based non-profit organization, supports a network of California primary care clinics in adopting an evidence-based model of care for returning community members. In 2020, TCN linked the California Department of Corrections and Rehabilitation (CDCR) and 21 TCN-affiliated clinics to create the Reentry Health Care Hub, supporting patient linkages to care post-release. From April 2020-August 2022, the Hub received 8420 referrals from CDCR to facilitate linkages to clinics offering medical, behavioral health, and substance use disorder services, as well as community health workers with histories of incarceration. This program description identifies care continuity components critical for reentry, including data sharing between carceral and community health systems, time and patient access for pre-release care planning, and investments in primary care resources. This collaboration is a model for other states, especially after the Medicaid Reentry Act and amid initiatives to improve care continuity for returning community members, like California's Medicaid waiver (CalAIM).

Personal Health Libraries for People Returning From Incarceration: Protocol for a Qualitative Study

BACKGROUND

Individuals released from carceral facilities have high rates of hospitalization and death, especially in the weeks immediately after their return to community settings. During this transitional process, individuals leaving incarceration are expected to engage with multiple providers working in separate, complex systems, including health care clinics, social service agencies, community-based organizations, and probation and parole services. This navigation is often complicated by individuals' physical and mental health, literacy and fluency, and socioeconomic status. Personal health information technology, which can help people access and organize their health information, could improve the transition from carceral systems to the community and mitigate health risks upon release. Yet, personal health information technologies have not been designed to meet the needs and preferences of this population nor tested for acceptability or use.

OBJECTIVE

The objective of our study is to develop a mobile app to create personal health libraries for individuals returning from incarceration to help bridge the transition from carceral settings to community living.

METHODS

Participants were recruited through Transitions Clinic Network clinic encounters and professional networking with justice-involved organizations. We used qualitative research methods to assess the facilitators and barriers to developing and using personal health information technology for individuals returning from incarceration. We conducted individual interviews with people just released from carceral facilities (n=~20) and providers (n=~10) from the local community and carceral facilities involved with the transition for returning community members. We used rigorous rapid qualitative analysis to generate thematic output characterizing the unique circumstances impacting the development and use of personal health information technology for individuals returning from incarceration and to identify content and features for the mobile app based on the preferences and needs of our participants.

RESULTS

As of February 2023, we have completed 27 qualitative interviews with individuals recently released from carceral systems (n=20) and stakeholders (n=7) who support justice-involved individuals from various organizations in the community.

CONCLUSIONS

We anticipate that the study will characterize the experiences of people transitioning from prison and jails to community settings; describe the information, technology resources, and needs upon reentry to the community; and create potential pathways for fostering engagement with personal health information technology.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44748.

Characteristics of recently incarcerated primary care patients with and without a positive posttraumatic stress disorder screening upon clinic intake

OBJECTIVE

Posttraumatic stress disorder (PTSD) is prevalent among people who have been incarcerated. Here, we examined whether screening positive for PTSD was associated with other indicators of poor health, acute healthcare utilization, and poverty among primary care patients upon release from incarceration.

METHOD

We conducted a cross-sectional survey in a national network of primary care clinics serving people recently released from incarceration. Participants were 416 patients who completed the Primary Care PTSD screen (PC-PTSD) and other questions about mental and physical health, acute healthcare utilization, and economic status within 6 months of release.

RESULTS

Screening positive for PTSD was associated with worse status across nearly all variables examined, including being more likely to report: poor/fair health (61.6% vs. 41.7%), current depressive symptoms (89.7% vs. 50.8%), lifetime depression diagnosis (63.3% vs. 35.3%), cannabis use since release (20.7% vs. 9.6%), homelessness (31.9% vs. 18.5%), having no cash on hand (56.3% vs. 39.0%) and severe food insecurity (29.3% vs. 18.2%; all ps < .01). Reporting recent suicidality (14.3% vs. 7.0%), alcohol use since release (30.2% vs. 20.0%), and emergency department utilization (20.4% vs. 12.2%) was also more likely (all ps ≤ .03). These trends were largely upheld when controlling for demographic characteristics and chronic physical health conditions using linear probability regression.

CONCLUSIONS

Primary care patients recently released from incarceration have a need for wrap-around services that address health challenges and poverty. Patients with significant PTSD symptoms face even greater challenges. Identification and treatment of PTSD both during and after incarceration is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cost savings of a primary care program for individuals recently released from prison: a propensity-matched study

Background

Criminal justice system costs in the United States have exponentially increased over the last decades, and providing health care to individuals released from incarceration is costly. To better understand how to manage costs to state budgets for those who have been incarcerated, we aimed to assess state-level costs of an enhanced primary care program, Transitions Clinic Network (TCN), for chronically-ill and older individuals recently released from prison.

Methods

We linked administrative data from Connecticut Department of Correction, Medicaid, and Department of Mental Health and Addiction Services to identify a propensity matched comparison group and estimate costs of a primary care program serving chronically-ill and older individuals released from incarceration between 2013 and 2016. We matched 94 people released from incarceration who received care at a TCN program to 94 people released from incarceration who did not receive care at TCN program on numerous characteristics. People eligible for TCN program participation were released from incarceration within the prior 6 months and had a chronic health condition or were over the age of 50. We estimated 1) costs associated with the TCN program and 2) costs accrued by Medicaid and the criminal justice system. We evaluated associations between program participation and Medicaid and criminal justice system costs over a 12-month period using bivariate analyses with nonparametric bootstrapping method.

Results

The 12-month TCN program operating cost was estimated at $54,394 ($146 per participant per month). Average monthly Medicaid costs per participant were not statistically different between the TCN ($1737 ± $3449) and comparison ($1356 ± $2530) groups. Average monthly criminal justice system costs per participant were significantly lower among TCN group ($733 ± $1130) compared with the matched group ($1276 ± $1738, p < 0.05). We estimate every dollar invested in the TCN program yielded a 12-month return of $2.55 to the state.

Conclusions

Medicaid investments in an enhanced primary care program for individuals returning from incarceration are cost neutral and positively impact state budgets by reducing criminal justice system costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07985-5.

The Transitions Clinic Network: Post Incarceration Addiction Treatment, Healthcare, and Social Support (TCN-PATHS): A hybrid type-1 effectiveness trial of enhanced primary care to improve opioid use disorder treatment outcomes following release from jail

BACKGROUND

In 2016, at least 20% of people with opioid use disorder (OUD) were involved in the criminal justice system, with the majority of individuals cycling through jails. Opioid overdose is the leading cause of death and a common cause of morbidity after release from incarceration. Medications for OUD (MOUD) are effective at reducing overdoses, but few interventions have successfully engaged and retained individuals after release from incarceration in treatment.

OBJECTIVE

To assess whether follow-up care in the Transitions Clinic Network (TCN), which provides OUD treatment and enhanced primary care for people released from incarceration, improves key measures in the opioid treatment cascade after release from jail. In TCN programs, primary care teams include a community health worker with a history of incarceration, and they attend to social needs, such as housing, food insecurity, and criminal legal system contact, along with patients' medical needs.

METHODS AND ANALYSIS

We will bring together six correctional systems and community health centers with TCN programs to conduct a hybrid type-1 effectiveness/implementation study among individuals who were released from jail on MOUD. We will randomize 800 individuals on MOUD released from seven local jails (Bridgeport, CT; Niantic, CT; Bronx, NY; Caguas, PR; Durham, NC; Minneapolis, MN; Ontario County, NY) to compare the effectiveness of a TCN intervention versus referral to standard primary care to improve measures within the opioid treatment cascade. We will also determine what social determinants of health are mediating any observed associations between assignment to the TCN program and opioid treatment cascade measures. Last, we will study the cost effectiveness of the approach, as well as individual, organizational, and policy-level barriers and facilitators to successfully transitioning individuals on MOUD from jail to the TCN.

ETHICS AND DISSEMINATION

Investigation Review Board the University of North Carolina (IRB Study # 19-1713), the Office of Human Research Protections, and the NIDA JCOIN Data Safety Monitoring Board approved the study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. We will disseminate study data through a web-based platform designed to share data with TCN PATHS participants and other TCN stakeholders. Clinical trials.gov registration: NCT04309565.

Formerly Incarcerated Community Health Workers Engaging Individuals Returning From Incarceration Into Primary Care: Results From the Transition Clinic Network

Over half a million individuals return from United States prisons and millions more from jails every year, many of whom with complex health and social needs. Community health workers (CHWs) perform diverse roles to improve health outcomes in disadvantaged communities, but no studies have assessed their role as integrated members of a primary care team serving individuals returning from incarceration. Using data from participants who received primary care through the Transitions Clinic Network, a model of care that integrates CHWs with a lived experienced of incarceration into primary care teams, we characterized how CHWs address participant health and social needs during interactions outside of clinic visits for 6 months after participants established primary care. Among the 751 participants, 79% had one or more CHW interactions outside of the clinic documented. Participants with more comorbid conditions, longer stays during their most recent incarceration, and released with a prescription had more interactions with CHWs compared to those with fewer comorbidities, shorter stays, and no prescription at release. Median number of interactions was 4 (interquartile range, IQR 2–8) and 56% were in person. The most common issues addressed (34%) were social determinants of health, with the most common being housing (35%). CHWs working in interdisciplinary primary care teams caring for people with histories of incarceration perform a variety of functions for clients outside of scheduled primary care visits. To improve health outcomes among disadvantaged populations, CHWs should be able to work across multiple systems, with supervision and support for CHW activities both in the primary care clinic and within the community.

Perceived Discrimination Based on Criminal Record in Healthcare Settings and Self-Reported Health Status among Formerly Incarcerated Individuals

Perceived discrimination based on criminal record is associated with social determinants of health such as housing and employment. However, there is limited data on discrimination based on criminal record within health care settings. We examined how perceived discrimination based on criminal record within health care settings, among individuals with a history of incarceration, was associated with self-reported general health status. We used data from individuals recruited from 11 sites within the Transitions Clinic Network (TCN) who were released from prison within the prior 6 months, had a chronic health condition and/or were age 50 or older, and had complete information on demographics, medical history, self-reported general health status, and self-reported perceived discrimination (n = 743).Study participants were mostly of minority racial and ethnic background (76%), and had a high prevalence of self-reported chronic health conditions with half reporting mental health conditions and substance use disorders (52% and 50%, respectively), and 85% reporting one or more chronic medical conditions. Over a quarter (27%, n = 203) reported perceived discrimination by health care providers due to criminal record with a higher proportion of individuals with fair or poor health reporting discrimination compared to those in good or excellent health (33% vs. 23%; p = .002). After adjusting for age and reported chronic conditions, participants reporting discrimination due to criminal record had 43% increased odds of reporting fair/poor health (AOR 1.43, 95% CI 1.01-2.03). Race and ethnicity did not modify this relationship.Participants reporting discrimination due to criminal record had increased odds of reporting fair/poor health. The association between perceived discrimination by health care providers due to criminal record and health should be explored in future longitudinal studies among individuals at high risk of incarceration.Clinical Trial Registration: NCT01863290.

Propensity-matched study of enhanced primary care on contact with the criminal justice system among individuals recently released from prison to New Haven

BACKGROUND

Health systems can be integral to addressing population health, including persons with incarceration exposure. Few studies have comprehensively integrated state-wide data to assess how the primary care system can impact criminal justice outcomes. We examined whether enhanced primary care can decrease future contact with the criminal justice system among individuals just released from prison.

METHODS

We linked administrative data (2013-2016) of Connecticut Department of Correction, Department of Mental Health and Addiction Services, Department of Social Service, Court Support Services Division, and Department of Public Health to conduct a quasi-experimental study using propensity score matching of 94 participants who received enhanced primary care in Transitions Clinic to 94 controls not exposed to the programme. The propensity score included 23 variables, which encompassed participants' medical and incarceration history and service utilisation. The main outcomes were reincarceration rates and days incarcerated in the first year from the index date, which was either enrolment in the Transitions Clinic programme or release from prison in the control group.

RESULTS

The odds of reincarceration, including arrests and new convictions, were similar for the two groups, but Transitions Clinic participants had lower odds of returning to prison for a parole or probation technical violation (adjusted OR: 0.38; 95% CI 0.16 to 0.93) compared with the control group. Further, Transitions Clinic participants had fewer incarceration days (incidence rate ratio: 0.55; 95% CI 0.35 to 0.84) compared with the control group.

CONCLUSIONS

Enhanced primary care for individuals just released from prison can reduce reincarceration for technical violations and shorten time spent within correctional facilities. This study shows how community health systems may play a role in current strategies to reduce prison populations.

Illicit substance use after release from prison among formerly incarcerated primary care patients: a cross-sectional study

Background

More than 80% of people in jail or prison report having used illicit substances in their lifetimes. After release from incarceration, resumption of substance use carries risks, including parole revocation, exacerbation of mental health conditions, transmission of infectious diseases, and drug overdose.

Methods

This cross-sectional study used baseline data from the Transitions Clinic Network (TCN, www.transitionsclinic.org), a multi-site prospective longitudinal cohort study of post-incarceration medical care. We investigated substance use among adults, with at least one chronic health condition or age ≥ 50 years, who had been recently released from incarceration and initiated care at a TCN site. Our primary outcome was any self-reported illicit substance use (heroin or other opioids, cocaine, cannabis, amphetamines, hallucinogens, MDMA, or illicit use of prescription medications) following release from incarceration. Alcohol use post-release was a secondary outcome. Using multivariable logistic regression, we also explored factors associated with illicit substance use.

Results

Among 751 participants, median age was 47; participants were mostly male (85%), non-white (47% black, 30% Hispanic), and on parole (80%). The proportion of participants reporting any illicit substance use and any alcohol use soon after release from incarceration was 18% and 23%, respectively. In multivariable regression, variables significantly associated with post-release illicit substance use were male gender (aOR = 3.91, 95% CI: 1.73–8.81), housing with friends or family (aOR = 3.33, 95% CI: 1.20–9.28), years incarcerated during latest prison term (aOR = 0.93, 95% CI: 0.89–0.98), weeks elapsed before engagement with TCN (aOR = 1.07, 95% CI: 1.03–1.10), being on parole (aOR = 0.58, 95% CI: 0.34–0.99), and having a drug use disorder (aOR = 2.27, 95% CI: 1.40–3.68).

Conclusions

Among individuals seeking medical care after release from incarceration, self-reported substance use was lower than previously reported estimates of post-incarceration substance use. Known risk factors, such as male gender and having a drug use disorder, were associated with illicit substance use, as were novel risk factors, such as less supervised housing. Though illicit substance use post-incarceration can carry severe consequences, treatment and surveillance interventions should be targeted toward individuals with greatest risk.

Adolescent varicocele: Efficacy of indication-to-treat protocol and proposal of a grading system for postoperative hydroceles

BACKGROUND

Varicocele is a common urologic anomaly in adolescent males; however, evidence-based treatment guidelines do not exist. Hydroceles are known to be a common complication after surgical therapy, with a wide variation in the reported incidence between 1 and 40%.

AIM

This study aimed to introduce a standardized indication-to-treat protocol and prove its efficacy by analyzing the outcome of patients. Secondly, it aimed to better define postoperative hydroceles because the wide variation of reported incidence is attributed to a lack of definition.

METHODS

Our standardized treatment protocol included an initial assessment with clinical grading of varicoceles, ultrasound evaluation of testicular volume, and calculation of the atrophy index. Indications for surgical treatment were testicular volume asymmetry >20%, discomfort and pain, or bilateral varicocele. The Palomo procedure (laparoscopically since 2005) was the standard procedure. Postoperative hydroceles were graded according to clinical findings and symptoms: Grade I, sonographic chance finding without clinical correlate; Grade II, palpable but clinically insignificant; Grade III, symptomatic. All patients treated according to the defined protocol were prospectively monitored between January 2001 and December 2015.

RESULTS

A total of 129 patients with left varicocele were referred to our institution; 70 fulfilled the indication criteria for surgical treatment. Twenty-eight of these patients were treated for volume asymmetry, 26 of these showed catch-up growth. Forty-two patients were treated for discomfort and pain; the symptoms subsided in all of them. Postoperative hydroceles were detected in 36 patients (51%). In 29 patients this was a sonographic chance finding (Grade I). Three patients showed a palpable but clinically insignificant postoperative hydrocele (Grade II) and four patients (5.7%) showed symptomatic hydrocele (Grade III) where treatment was recommended.

DISCUSSION

The treatment protocol allowed judicious indication for surgery and postoperative outcomes similar to previous reports. The high rate of catch-up growth in operated cases represents a proxy for successful treatment in cases where more precise parameters, like semen quality or paternity rate, were not yet detectable. The introduced grading system for postoperative hydroceles provs to be a valid and appropriate instrument, and promises to be a standardized method for comparing outcomes in future studies.

CONCLUSION

The indication-to-treat protocol proved to be easily applicable, highly efficient, and have outcomes comparable to international literature. The necessity for a standardized grading of postoperative hydroceles was underscored in the data.

Engaging individuals recently released from prison into primary care: a randomized trial

OBJECTIVES

Individuals released from prison have high rates of chronic conditions but minimal engagement in primary care. We compared 2 interventions designed to improve primary care engagement and reduce acute care utilization: Transitions Clinic, a primary care-based care management program with a community health worker, versus expedited primary care.

METHODS

We performed a randomized controlled trial from 2007 to 2009 among 200 recently released prisoners who had a chronic medical condition or were older than 50 years. We abstracted 12-month outcomes from an electronic repository available from the safety-net health care system. Main outcomes were (1) primary care utilization (2 or more visits to the assigned primary care clinic) and (2) emergency department (ED) utilization (the proportion of participants making any ED visit).

RESULTS

Both groups had similar rates of primary care utilization (37.7% vs 47.1%; P = .18). Transitions Clinic participants had lower rates of ED utilization (25.5% vs 39.2%; P = .04).

CONCLUSIONS

Chronically ill patients leaving prison will engage in primary care if provided early access. The addition of a primary care-based care management program tailored for returning prisoners reduces ED utilization over expedited primary care.

Transitions clinic: creating a community-based model of health care for recently released California prisoners

Most California prisoners experience discontinuity of health care upon return to the community. In January 2006, physicians working with community organizations and representatives of the San Francisco Department of Public Health's safety-net health system opened the Transitions Clinic (TC) to provide transitional and primary care as well as case management for prisoners returning to San Francisco. This article provides a complete description of TC, including an illustrative case, and reports information about the recently released individuals who participated in the program. From January 2006 to October 2007, TC saw 185 patients with chronic medical conditions. TC patients are socially and economically disenfranchised; 86% belong to ethnic minority groups and 38% are homeless. Eighty-nine percent of patients did not have a primary care provider prior to their incarceration. Preliminary findings demonstrate that a community-based model of care tailored to this disenfranchised population successfully engages them in seeking health care.

Transitions clinic: creating a community-based model of health care for recently released California prisoners

Most California prisoners experience discontinuity of health care upon return to the community. In January 2006, physicians working with community organizations and representatives of the San Francisco Department of Public Health's safety-net health system opened the Transitions Clinic (TC) to provide transitional and primary care as well as case management for prisoners returning to San Francisco. This article provides a complete description of TC, including an illustrative case, and reports information about the recently released individuals who participated in the program. From January 2006 to October 2007, TC saw 185 patients with chronic medical conditions. TC patients are socially and economically disenfranchised; 86% belong to ethnic minority groups and 38% are homeless. Eighty-nine percent of patients did not have a primary care provider prior to their incarceration. Preliminary findings demonstrate that a community-based model of care tailored to this disenfranchised population successfully engages them in seeking health care.

Antiphospholipid antibodies bind ATP: a putative mechanism for the pathogenesis of neuronal dysfunction

Antiphospholipid antibodies (aPL) generated in experimental animals cross-react with ATP. We therefore examined the possibility that aPL IgG from human subjects bind to ATP by affinity column and an enzyme linked immunosorbent assay (ELISA). Sera with high levels of aPL IgG were collected from 12 patients with the antiphospholipid syndrome (APS). IgG fractions from 10 of 12 APS patients contained aPL that could be affinity-bound to an ATP column and completely eluted with NaCl 0.5 M. A significant (>50%) inhibition of aPL IgG binding by ATP 5 mM was found in the majority. Similar inhibition was obtained with ADP but not with AMP or cAMP. All the affinity purified anti-ATP antibodies also bound β₂-glycoprotein-I (β₂-GPI, also known as apolipoprotein H) suggesting that, similar to most pathogenic aPL, their binding depends on this serum cofactor. We further investigated this possibility and found that the binding of β₂-GPI to the ATP column was similar to that of aPL IgG in that most was reversed by NaCl 0.5 M. Furthermore, addition of β₂-GPI to aPL IgG significantly increased the amount of aPL binding to an ATP column. We conclude that aPL IgG bind ATP, probably through β₂-GPI. This binding could interfere with the normal extracellular function of ATP and similar neurotransmitters.

Subunit specificity and mechanism of action of NMDA partial agonist D-cycloserine

Recently, we have shown that 1-aminocyclopropanecarboxylic acid (ACPC) acts simultaneously as a high affinity full glycine agonist and a low affinity glutamate site competitive antagonist for NMDA receptor channels. In this paper, we have attempted to determine the subunit specificity and mechanism of action of a different putative cyclic partial agonist, D-cycloserine (DCS). NMDA receptor currents were measured utilizing the two-electrode voltage clamp technique on Xenopus oocytes injected with NR1-1a cRNA and either NR2A, NR2B or NR2C cRNA. Efficacies of DCS were 35-68% of glycine controls for channels containing NR1-1a and NR2A or NR2B subunits, but channels containing NR2C subunits had efficacies greater than glycine controls (192%). Unlike ACPC, DCS efficacy does not increase with increasing NMDA concentration; however, the lowered efficacy elicited by DCS results solely through its interaction with the glycine binding site. The efficacy of DCS was pH sensitive for NR2A or NR2B-containing channels, but not for channels containing NR2C. From this, we suggest that the protonated and deprotonated forms of DCS when bound, probably open NMDA channels with different efficiency. Two models compatible with these results are presented.

Desensitization of NMDA receptor channels is modulated by glutamate agonists

Two distinct forms of desensitization have been characterized for N-methyl-D-aspartate (NMDA) receptors. One form results from a weakening of agonist affinity when channels are activated whereas the other form of desensitization results when channels enter a long-lived nonconducting state. A weakening of glycine affinity upon NMDA receptor activation has been reported. Cyclic reaction schemes for NMDA receptor activation require that a concomitant affinity shift should be observed for glutamate agonists. In this study, measurements of peak and steady-state NMDA receptor currents yielded EC50 values for glutamate that differed by 1.9-fold, but no differences were found for another agonist, L-cysteine-S-sulfate (LCSS). Simulations show that shifts in EC50 values may be masked by significant degrees of desensitization resulting from channels entering a long-lived nonconducting state. Simulations also show that a decrease in the degree of desensitization with increasing agonist concentration is a good indicator for the existence of desensitization resulting from a weakening of agonist affinity. Both glutamate and LCSS exhibited this trend. An affinity difference of three- to eightfold between high-and low-affinity agonist-binding states was estimated from fitting of dose-response data with models containing both types of desensitization. This indicates that activation of NMDA receptors causes a reduction in both glutamate and glycine affinities.

Antibodies to brain antigens following stroke

Cerebral necrosis following stroke exposes brain antigens to the immune system, potentially initiating an antibody response. The authors measured levels of antibodies to specific neuronal antigens, neurofilaments (NF), and a ubiquitous antigen, cardiolipin (CL), in 45 patients following an acute first-ever stroke, within 48 hours, and 1, 3, and 6 months later. The mean levels of anti-NF antibodies were elevated compared with baseline at 1, 3, and 6, months (p = 0.012, 0.002, and 0.003 by paired t-test). Anti-CL levels did not change significantly.

From hand twister to mind twister: computer-aided treatment in traumatic wrist fracture

OBJECTIVE

The use of computers as a treatment modality in the occupational therapy hand clinic is, as yet, not common practice. A computer interface for wrist movements was developed, and a study to justify the application of such a device is presented.

METHOD

Forty-seven patients in a day hand clinic who had traumatic fracture of one hand with limitation of wrist mobility participated in the study. Participants were divided into two treatment groups: computer-aided treatment (high technology) and traditional brush machine treatment (low technology). A device was developed based on the brush machine in which the brush machine's mechanism was converted into a medial-lateral joystick. Right-to-left movements were digitally transformed for the use of a computer game. Participants were treated for 5 weeks, and outcome measures included range of motion (ROM), grip strength, edema, and level of interest.

RESULTS

Results showed significant improvement in ROM, grip strength, and edema across 5 weeks for all participants. Although no significant differences were found between the two groups in ROM, grip strength, and edema, the computer-aided group showed significantly more interest in treatment than did the brush machine group. Finally, the interaction between treatment group and the attitude toward computers was not significant.

CONCLUSIONS

These results indicate the potential for more interesting motor treatment and rehabilitation of the wrist through the use of computer games. The efficacy of using computers in occupational therapy clinics needs further investigation.

Antibodies to prothrombin in patients with Sneddon's syndrome

Antiprothrombin antibodies (aPT), a new serologic marker of antiphospholipid syndrome, were studied in 46 patients randomly selected from 73 with Sneddon's syndrome and 20 matched normal controls. aPT were elevated in 26 patients (57%) and were not found in any of the controls. The addition of aPT data increased the proportion of Sneddon's syndrome patients with at least one type of antiphospholipid syndrome marker from 65 to 78%. The finding that aPT are common in Sneddon's syndrome supports the hypothesis that Sneddon's syndrome is a form of antiphospholipid syndrome.

Antineurofilament antibodies in postpolio syndrome

We determined the levels of antineurofilament antibodies in 29 patients with postpolio syndrome (PPS), 26 stable postpolio (PP) patients, 22 patients with ALS, and 20 normal controls (NCs). Patients with PPS had higher antibody levels to cholinergic neurofilaments than did all other groups. PP patients and those with ALS had antibody levels similar to those of NCs. The antibody binding level showed no relation to the age of the patients, duration of disease, or motor score.

[Sneddon syndrome new clinical and immunological data]

In 27 of 47 patients with Sneddon's syndrome (33 females, 14 males age 40 years) enzyme immunoassay has detected IgG-antibodies to prothrombin (aPT)--one of cofactor proteins responsible for binding of antiphospholipid antibodies (aPL) to phospholipids. Other aPL were also found: antibodies to cardiolipin (aCL), lupus anticoagulant (LA) in 14 and 27 patients, respectively. 37 (79%) patients had at least one of the studied aPL suggesting that such patients belong to patients with primary antiphospholipid syndrome. A correlation exists between aPT and LA: LA is detectable in 67% of aPT-positive patients compared to 45% of aPT-negative patients (p < 0.05). This is in agreement with the fact that prothrombin is a cofactor for most aPL registered as LA. Comparison of two subgroups of aPL patients different by dominant antigenic specificity (18 patients with aPT but free of ACL and 6 patients with aCP but free of aPT) demonstrated that the latter developed disorders of cerebral circulation, head ache, dementia and renal syndrome less frequently. aPT in Sneddon's syndrome seems to be a marker of comparatively low risk of thrombosis and less severe course of the disease.

Interaction between antidepressants and phosphoinositide signal transduction system in human platelets

The present study was designed to evaluate the inhibitory effect of antidepressants on thrombin-induced phosphoinositide (PI) hydrolysis. Thrombin 5 units/ml induced a 100%-200% increase in platelet inositol phosphates (IPs) formation. This effect was inhibited in a dose-dependent manner by various heterocyclic antidepressants (IC50 40-170 mumol/L) The monoamine oxidase inhibitor, phenelzine, in concentrations up to 500 mumol/L, was devoid of inhibitory activity. The tricyclic antidepressants, (50 mumol/L) inhibited also thrombin-induced platelet aggregation by 32%-47%. No alteration in thrombin-induced IPs formation was detected in recovered major depressed patients (n = 15) maintained on clomipramine (75-150 mg/day). These results indicate that the heterocyclic antidepressants interfere with the thrombin-linked PI-signaling system. However, the inhibitory effect is achieved only in concentrations above the plasma concentrations obtained with therapeutic doses of these agents.

The pupillary effects of retrobulbar injection of botulinum toxin A (oculinum) in albino rats

Botulinum toxin (BoTx) has been clinically used in the treatment of localized dystonic states such as blepharospasm, as well as in strabismus. Reported side effects have included primary excessive weakness of neighboring extraocular muscles. To evaluate possible involvement of the iris, we injected BoTx into the retrobular space of albino rats. Ipsilateral mydriasis with cholinomimetic supersensitivity developed in the treated animals. There was no apparent optic nerve dysfunction. The authors observed these effects using BoTx doses insufficient to cause clinical weakness or electrophysiological evidence of generalized neuromuscular dysfunction. The mydriasis disappeared spontaneously within 2-3 weeks. Higher BoTx doses resulted in severe neuromuscular paralysis and death. These findings were consistent with clinical botulism, which may include autonomic paralysis. The site of BoTx action could be the ciliary ganglion or cholinergic terminals in the iris. The authors concluded that side effects of BoTx were not necessarily limited to striated muscle weakness.

Sympathomimetic amines and cardiac arrhythmias

STUDY OBJECTIVE

The aim was to investigate the arrhythmogenic properties of several sympathomimetic amines and their antagonism by adrenergic blocking drugs.

DESIGN

Arrhythmia was induced by the investigated drugs, injected intravenously: adrenaline (ADR); noradrenaline (NA); phenylephrine (PE); isoprenaline (IP); terbutaline (Tb) and salbutamol (Sb). ADR and PE were also tested for their arrhythmogenic properties after the administration of the adrenergic antagonists propranolol, phentolamine, or both. The dose required to induce arrhythmia and the proportion of animals that developed arrhythmia at a given dose were recorded.

SUBJECTS

63 anaesthetised cats of either sex, weight 2.0-4.3 kg, were used.

MEASUREMENTS AND RESULTS

The electrocardiogram was recorded continuously. The arrhythmogenic potency sequence (expressed as arrhythmogenic dose, AD50 in micrograms) was: ADR 16; NA 24; PE 75; IP 133; Tb 500; Sb greater than 1000. The arrhythmogenic efficacy (in %) was: ADR 97; NA 91; PE 90; IP 82; Tb 50; and Sb 0. Propranolol and phentolamine were both effective in reducing the arrhythmogenic effects of ADR and PE. However, their combined administration was most effective and abolished the arrhythmias.

CONCLUSIONS

Arrhythmogenicity is a property of sympathomimetic amines with either alpha or beta adrenergic effects, but simultaneous activation of both types of receptors is required for maximal manifestations. Similarly, antagonism at both sites is necessary in order to abolish arrhythmias induced by sympathomimetic amines completely.

Nicotine mydriasis

In mice, nicotine produces dose-dependent mydriasis following interperitoneal or intracerebroventicular administration but not after local application through the conjunctival sac. Since mydriasis is not prevented by cervical sympathectomy, it is likely to be due to central inhibition of the parasympathetic tone. Repeated administration of nicotine over 8 h progressively diminished and finally obliterated the response to a test dose of nicotine. This acute tolerance was maintained for 24 h. Tolerance was also produced by daily administration of nicotine and lasted up to 12 days after withdrawal. The easily measurable examination of the pupillary responses provide a convenient method for the investigation of mechanisms underlying tolerance to nicotine.

Cardiac denervation supersensitivity produced in guinea pigs by 6-hydroxy-dopamine

The effects of chemical sympathectomy with 6-hydroxydopamine (6-OH-DA) on the sensitivity of guinea-pig heart to catecholamines were studied. Heart rate at rest and chronotropic effects of catecholamines remained unchanged after chemical sympathectomy, while the arrhythmogenic effects of epinephrine, norepinephrine and isoprenaline were potentiated markedly. Our results indicate that chemical sympathectomy with 6-OH-DA produced post synaptic denervation supersensitivity in the heart ventricles.

Agonist interaction and decentralization supersensitivity in the nictitating membrane of the cat

1. The responses to individual drugs and to combinations of two drugs were studied in normal and chronically decentralized nictitating membranes (NM) of cats. Noradrenaline (NA), acetylcholine (ACh), serotonin (5HT) and potassium chloride (KCl) and the combinations NA + ACh, NA + 5HT, NA + KCl and ACh + 5HT were injected intra-arterially towards the smooth muscle. 2. Chronic decentralization resulted in supersensitivity to each of these agonists when injected alone. 3. The contraction of the normal NM caused by each drug combination showed potentiation in comparison to the sum of contractions caused by the same drugs given separately. The same drug combinations showed no potentiation in decentralized muscle. 4. Decentralization supersensitivity and potentiation due to agonist interactions in normal preparations may share a common mechanism. The involvement of calcium in this phenomenon is discussed.

The chick as a model for malignant hyperpyrexia

Administration of succinylcholine (SCh) to chicks produces rigid paralysis and death due to respiratory impairment. The mechanism of the SCh effect is probably related to the multiple innervation of muscle fibres, leading to excessive intracellular accumulation of calcium. This situation may be similar to that in malignant hyperpyrexia (MH) occurring in mammals. Dantrolene sodium, phenytoin and procain, drugs used against MH, were found to afford protection against SCh rigidity and death in chicks. It is suggested that the chick can be used as a convenient model for rapid screening of drugs potentially active against NH.

Prolongation of responses in decentralization supersensitivity

In chronically decentralized nictitating membranes of cats the responses to norepinephrine and to acetylcholine were markedly prolonged. The increased duration was not directly related to the increased amplitude of the contractions. It is likely to be due to a change of the muscle itself.