An evaluation of online discussion relating to nonmedical use of prescription opioids within the UK.

AIM: To identify and describe the nature of online discussion relating to prescription opioids within the UK. METHODS: We performed analysis of posts originating in the UK related to buprenorphine, hydrocodone, oxycodone and tramadol using Social Studio, a web-monitoring platform. The study included posts published between January 2014 and December 2016. The data were cleaned to produce a final dataset consisting only of substantive mentions, which were then categorised by defined themes. RESULTS: The final dataset included a total of 17 361 substantive mentions (2936 buprenorphine, 2894 hydrocodone, 3826 oxycodone and 7705 tramadol). The most common theme for all 4 drugs was sharing experience or opinion comprising over 90% of mentions for each drug, while discussion related to polysubstance use was present in >1/4 of mentions across drug substances. Mentions related to diversion were more common for hydrocodone and oxycodone (8.1% [6.3-10.1 95% confidence interval] and 7.8% [6.5-9.2], respectively) than buprenorphine or tramadol (4.1 and 3.9% [3.5-4.3], respectively). CONCLUSION: This investigation shows that there is substantial online discussion relating to a variety of nonmedical use (NMU) behaviours of prescription opioids within the UK, including for hydrocodone, which is not medically available. Web monitoring provides useful data and merits future investigation; this could include expansion to other categories of drugs and a more in-depth analysis of motivations behind NMU, both of which could add timely evidence regarding the current situation in the UK and help inform public health interventions for NMU of prescription drugs.

Mass vaccination clinics versus appointments.

Influenza vaccine is a safe, effective, and cost-effective intervention that can prevent serious disease in adults. Opinions differ as to the most effective method for delivering the vaccine to the greatest number of high-risk adults. The objective of this article is to compare immunization delivery of influenza vaccine to high-risk adults during two types of clinic visits: routine scheduled appointments versus mass clinics. Data was collected at 15 ambulatory care settings on 599 patients 50 years and over from October 23, 2001, to January 31, 2002. Immunizations given at either routine scheduled visits or at mass influenza immunization clinics were compared for costs and resource requirements (productivity), and completeness of delivery of quality visit components (efficiency). The two visit types presented significantly different strengths on key clinical functions. Routine scheduled appointments promoted more review of patient health history and more of the contact information necessary for reminder/recall and audit functions. In mass immunization clinics, patients were more likely to be vaccinated, with far less time spent in either direct services or in waiting, and it was more likely that the required vaccination information statements (VIS) would be provided. Mass vaccination clinics and routine scheduled appointments are both viable service strategies for delivering influenza vaccines. This study suggests the greatest advantage occurs when both strategies are used in a coordinated manner.

Utility of graded prognostic assessment in evaluation of patients with brainstem metastases treated with radiosurgery.

OBJECTIVES: Prospective data regarding the safety and efficacy of stereotactic radiosurgery (SRS) for patients with metastatic disease involving the brainstem are lacking. The aim of this study was to assess the efficacy and toxicity of SRS for patients with brainstem metastases treated at our institution. PATIENTS AND METHODS: From September 2007 to October 2015, patients treated with SRS for brain metastases were prospectively entered into an institutional database. Forty eight patients with 51 lesions involving the brainstem with clinical follow-up were identified. Local control (LC), elsewhere brain failure (EBF) and overall survival (OS) were assessed from the date of radiosurgery using the Kaplan-Meier method. Univariate and multivariate analyses of factors related to OS were performed using a Cox proportional hazards model. RESULTS: Median clinical follow-up was 4.8 months. Median patient age was 62 (range: 28-87); non-small cell lung and breast cancer were the most common primaries at 54% and 21% respectively. Median brainstem lesion volume was 0.12cm(3) (range: 0.01-3.67cm(3)). Whole brain radiotherapy was previously utilized in 19 patients (40%). The median OS was 7.6 months and the 12 month LC rate was 89%. Only 2 patients (4%) experienced grade 3 motor toxicity secondary to SRS. 11 of the 16 patients (69%) initially presenting with symptoms related to brainstem metastases had symptom improvement or resolution following SRS. On multivariate analysis, graded prognostic assessment (GPA) score>2 was predictive of improved survival (p<0.01) while prior chemotherapy use predicted decreased survival (p=0.049). CONCLUSIONS: SRS is associated with high LC rates and low toxicity for brainstem metastases. Improved OS was seen for patients with GPA score>2. GPA appears to be a useful tool for assessing prognosis in patients with brainstem metastases. Small volume lesions were safely treated with or without prior whole brain radiotherapy.

Surgical Resection of Brain Metastases and the Risk of Leptomeningeal Recurrence in Patients Treated With Stereotactic Radiosurgery.

PURPOSE: Recent prospective data have shown that patients with solitary or oligometastatic disease to the brain may be treated with upfront stereotactic radiosurgery (SRS) with deferral of whole-brain radiation therapy (WBRT). This has been extrapolated to the treatment of patients with resected lesions. The aim of this study was to assess the risk of leptomeningeal disease (LMD) in patients treated with SRS to the postsurgical resection cavity for brain metastases compared with patients treated with SRS to intact metastases. METHODS AND MATERIALS: Four hundred sixty-five patients treated with SRS without upfront WBRT at a single institution were identified; 330 of these with at least 3 months' follow-up were included in this analysis. One hundred twelve patients had undergone surgical resection of at least 1 lesion before SRS compared with 218 treated for intact metastases. Time to LMD and overall survival (OS) time were estimated from date of radiosurgery, and LMD was analyzed by the use of cumulative incidence method with death as a competing risk. Univariate and multivariate analyses were performed with competing risk regression to determine whether various clinical factors predicted for LMD. RESULTS: With a median follow-up time of 9.0 months, 39 patients (12%) experienced LMD at a median of 6.0 months after SRS. At 1 year, the cumulative incidence of LMD, with death as a competing risk, was 5.2% for the patients without surgical resection versus 16.9% for those treated with surgery (Gray test, P<.01). On multivariate analysis, prior surgical resection (P<.01) and breast cancer primary (P=.03) were significant predictors of LMD development. The median OS times for patients undergoing surgery compared with SRS alone were 12.9 and 10.6 months, respectively (log-rank P=.06). CONCLUSIONS: In patients undergoing SRS with deferral of upfront WBRT for intracranial metastatic disease, prior surgical resection and breast cancer primary are associated with an increased risk for the development of LMD.

Trigeminal neuralgia pain relief after gamma knife stereotactic radiosurgery.

OBJECTIVES: To report outcomes of patients with medical and/or surgical refractory trigeminal neuralgia (TN) treated with gamma knife stereotactic radiosurgery (GK SRS). METHODS: One hundred and forty-nine patients with 152 cases of TN treated with GK SRS were analyzed. All patients, except one, received a dose of 40Gy to the 50% isodose volume. The Barrow Neurological Institute (BNI) pain intensity score was used to grade pain. Actuarial rates of pain relief were calculated. Multiple factors were analyzed for association with pain relief. RESULTS: The median follow up was 27 months (4-71 months). Overall 92% of cases achieved a BNI score I-III after GK SRS. Of those who had pain relief after GK SRS, 32% developed pain recurrence defined as a BNI score of IV or V. The actuarial rate of freedom from pain recurrence (BNI scores I-III) of all treated cases at 1, 2 and 3-years was 76%, 69% and 60%, respectively. On univariate analysis age ≥70 was predictive of better pain relief (p=0.046). Type of pain, prior surgery, multiple sclerosis, number of isocenters, treated nerve length, volume and thickness and distance from the root entry zone to the isocenter were not significant for maintaining a BNI score of I-III. Those who achieved a BNI score of I or II were more likely to maintain pain relief compared to those who only achieved a BNI score of III (93% vs 38% at three years, p<0.01). The rate of pain relief of twenty-seven patients who underwent repeat GK SRS was 70% and 62% at 1 and 2 years, respectively. Toxicity after first GK SRS was minimal with 25% of cases experiencing only new or worsening post-treatment numbness. CONCLUSION: GK SRS provides acceptable pain relief with limited morbidity in patients with medical and/or surgical refractory TN.

Tumor volume as a predictor of survival and local control in patients with brain metastases treated with Gamma Knife surgery.

OBJECT: The aim of this study was to examine tumor volume as a prognostic factor for patients with brain metastases treated with Gamma Knife surgery (GKS). METHODS: Two hundred fifty patients with 1-14 brain metastases who had initially undergone GKS alone at a single institution were retrospectively reviewed. Patients who received upfront whole brain radiation therapy were excluded. Survival times were estimated using the Kaplan-Meier method. Univariate and multivariate analyses using Cox proportional hazard regression models were used to determine if various prognostic factors could predict overall survival, distant brain failure, and local control. RESULTS: Median overall survival was 7.1 months and the 1-year local control rate was 91.5%. Median time to distant brain failure was 8.0 months. On univariate analysis an increasing total tumor volume was significantly associated with worse survival (p = 0.031) whereas the number of brain metastases, analyzed as a continuous variable, was not (p = 0.082). After adjusting for age, Karnofsky Performance Scale score, and extracranial disease on multivariate analysis, total tumor volume was found to be a better predictor of overall survival (p = 0.046) than number of brain metastases analyzed as a continuous variable (p = 0.098). A total tumor volume cutoff value of ≥ 2 cm(3) (p = 0.008) was a stronger predictor of overall survival than the number of brain metastases (p = 0.098). Larger tumor volume and extracranial disease, but not the number of brain metastases, were predictive of distant brain failure on multivariate analysis. Local tumor control at 1 year was 97% for lesions < 2 cm(3) compared with 75% for lesions ≥ 2 cm(3) (p < 0.001). CONCLUSIONS: After adjusting for other factors, a total brain metastasis volume was a strong and independent predictor for overall survival, distant brain failure, and local control, even when considering the number of metastases.

Executive functions in adolescents with spina bifida: relations with autonomy development and parental intrusiveness.

The current study was part of a larger longitudinal investigation and examined the relation of parent-report and performance measures of executive functioning (EF) with measures of behavioral and emotional autonomy and parental intrusiveness in adolescents with and without spina bifida (SB; n=65 in a comparison sample and 61 in an SB sample; M age=14.55, SD=0.63). For both groups, higher levels of parent-reported EF problems predicted higher levels of observed child dependency and lower levels of teacher-reported intrinsic motivation. Higher scores on performance EF measures predicted lower levels of observed child dependency and observed maternal intrusiveness for both groups. In adolescents with SB only, higher performance EF scores predicted higher intrinsic motivation and emotional autonomy from both mother and father and predicted lower levels of observed paternal intrusiveness. While causal conclusions cannot be drawn, EFs appear to be closely related to autonomy development and parental intrusiveness, particularly for adolescents with SB. These results suggest that the inclusion of EF training in interventions targeting adolescents with SB may be beneficial for autonomy development.

T1 hyperintense disc in alkaptonuria.

STUDY DESIGN: Case report. OBJECTIVE: To report a rare case of alkaptonuria presenting as a T1-hyperintense disc herniation. SUMMARY OF BACKGROUND DATA: A 46-year-old man without previous diagnosis of alkaptonuria underwent evaluation for progressive back pain revealing a T1-hyperintense disc herniation at the L3-L4 level. Discectomy recovered a blackened disc that was pathologically confirmed to be nucleus pulposus with alkaptonuric involvement. The differential diagnosis of a T1-hyperintense, T2-hypointense disc on magnetic resonance imaging is discussed, with emphasis on the pathophysiology of alkaptonuria. METHODS: A single patient is reported. RESULTS: Pathologically proven patient presentation with radiological and pathological images. CONCLUSION: We report a rare case of alkaptonuria presenting as a T1-hyperintense disc herniation.

The epidemiology of HIV among young people in sub-Saharan Africa: know your local epidemic and its implications for prevention.

BACKGROUND: Broad patterns of HIV epidemiology are frequently used to design generic HIV programs in sub-Saharan Africa. METHODS: We reviewed the epidemiology of HIV among young people in sub-Saharan Africa, and explored the unique dynamics of infection in its different regions. RESULTS: In 2009, HIV prevalence among youth in sub-Saharan Africa was an estimated 1.4% in males and 3.4% in females, but these values mask wide variation at regional and national levels. Within countries there are further major differences in HIV prevalence, such as by sex, urban/rural location, economic status, education, or ethnic group. Within this highly nuanced context, HIV prevention programs targeting youth must consider both where new infections are occurring and where they are coming from. CONCLUSIONS: Given the epidemiology, one-size-fits-all HIV prevention programs are usually inappropriate at regional and national levels. Consideration of local context and risk associated with life transitions, such as leaving school or getting married, is imperative to successful programming for young people.

Prevalence of aneuploidies in South Carolina in the 1990s.

PURPOSE: Folate insufficiency due to nutritional deficiency or folate processing gene mutations has been proposed as a trisomy 21 risk factor. This study examined the possibility that increased folic acid intake among women of childbearing age may decrease the prevalence of trisomy 21 and other aneuploidies. METHODS: The prevalence of aneuploidies from 1990 through 1999 was compared with folic acid use in women of childbearing age in South Carolina. RESULTS: Folic acid use and the prevalence of all aneuploidies significantly increased during this period. CONCLUSION: Increased folic acid utilization in South Carolina was not associated with decreased prevalence of trisomy 21 or other aneuploidies.

X-linked mental retardation with seizures and carrier manifestations is caused by a mutation in the creatine-transporter gene (SLC6A8) located in Xq28.

A family with X-linked mental retardation characterized by severe mental retardation, speech and behavioral abnormalities, and seizures in affected male patients has been found to have a G1141C transversion in the creatine-transporter gene SLC6A8. This mutation results in a glycine being replaced by an arginine (G381R) and alternative splicing, since the G-->C transversion occurs at the -1 position of the 5' splice junction of intron 7. Two female relatives who are heterozygous for the SLC6A8 mutation also exhibit mild mental retardation with behavior and learning problems. Male patients with the mutation have highly elevated creatine in their urine and have decreased creatine uptake in fibroblasts, which reflects the deficiency in creatine transport. The ability to measure elevated creatine in urine makes it possible to diagnose SLC6A8 deficiency in male patients with mental retardation of unknown etiology.