Can reinforcement-based interventions to reduce drug use successfully be adapted to routine opioid maintenance treatment?

INTRODUCTION: Comorbid substance related disorders are a major health problem for patients in opioid maintenance treatment (OMT). It was investigated whether a reinforcement scheme adapted to the regulatory and financial restrictions of routine treatment reduces concomitant drug use. METHODS: OMT patients from 7 clinics who were using cocaine, benzodiazepines, heroin or amphetamines were randomly allocated to either treatment as usual (n = 64) or treatment with an additional escalating reinforcement scheme (n = 72) in which a patient's number of weekly take-home dosages was increased after 1, 4, 8 and 12 consecutive weeks with drug-free urine specimens. Trial duration was 26 weeks. RESULTS: Completion rates were 64% for controls and 62.5% in the experimental group. Mean number of drug-free weeks was 11.3 (SD 8.5) for the control group and 9.8 (8.9) for the experimental group (p = 0.30). CONCLUSION: The intervention was not effective compared to routine treatment. Additional features might be necessary to achieve an effect, e.g. a higher frequency of urine sampling or use of other reinforcers. It has to be further investigated how interventions which have been proven effective in experimental studies can successfully be adapted to routine care conditions.

Fast scanning cavity offset lock for laser frequency drift stabilization.

We have implemented a compact setup for long-term laser frequency stabilization. Light from a stable reference laser and several slave lasers is coupled into a confocal Fabry-Perot resonator. By stabilizing the position of the transmission peaks of the slave lasers relative to successive peaks of the master laser as the length of the cavity is scanned over one free spectral range, the long-term stability of the master laser is transferred to the slave lasers. By using fast analog peak detection and low-latency microcontroller-based digital feedback, with a scanning frequency of 3 kHz, we obtain a feedback bandwidth of 380 Hz and a relative stability of better than 10 kHz at timescales longer than 1 s, a significant improvement on previous scanning-cavity stabilization systems.

Neural correlates of episodic and semantic memory retrieval in borderline personality disorder: an fMRI study.

Verbal memory impairment in borderline personality disorder (BPD) is still a matter of debate. In this study we combine investigations of both, memory retrieval as well as underlying neural circuits in BPD. Functional magnetic resonance imaging (fMRI) was used to study regional brain activation in 18 right-handed female patients with BPD and 18 matched controls during the retrieval of an episodic memory retrieval (EMR) task (free recall of a word list) and a semantic memory retrieval (SMR) task (verbal fluency). Despite unaffected performance in EMR and SMR, patients with BPD showed task-specific increased activation compared with controls. During EMR, the increased activation encompassed the posterior cingulate cortex bilaterally, the left middle and superior temporal gyrus, the right inferior frontal gyrus, and the right angular gyrus. SMR was associated with increased activation of the posterior cingulate cortex, of the right fusiform gyrus, of the left anterior cingulate cortex, and of the left postcentral gyrus. Our findings suggest that BPD patients may need to engage larger brain areas to reach a level of performance in episodic and semantic retrieval tasks that is comparable to that of healthy controls.

Stability of the dexamethasone suppression test in borderline personality disorder with and without comorbid PTSD: a one-year follow-up study.

Alterations in hypothalamic-pituitary-adrenal axis feedback regulation have been repeatedly reported in patients with borderline personality disorder (BPD). Due to the cross-sectional design of these studies, little is known about the longitudinal course of HPA axis functioning. In a sample of 13 patients with BPD, the dexamethasone suppression test (DST) has been used in a one-year follow-up study. There were no changes of cortisol concentrations before or after dexamethasone intake between baseline and follow-up examination. Patients with comorbid posttraumatic stress disorder (PTSD) showed more pronounced cortisol suppression compared to those without PTSD. The DST seems to be a stable marker of alterations in HPA axis feedback regulation in BPD, which is also reflected by substantial correlations between percentage of cortisol suppression at baseline and follow-up examination.

Deficits in visual functions and neuropsychological inconsistency in Borderline Personality Disorder.

For Borderline Personality Disorder (BPD) cognitive and perceptual impairments were reported in some but not all studies. The aim of the present study was to analyze the neuropsychological performance of BPD patients in different domains. Predominant impairments of visual functions and an increased intra-individual variation of test performances within neuropsychological domains were expected. We investigated 22 patients with BPD and a matched sample of 22 healthy control subjects. A comprehensive clinical and neuropsychological test battery was administered. Effect sizes indicate primarily deficits of visual functions such as visual memory (Wechsler Memory Scale-Revised, WMS-R: Visual pair associates and visual reproduction, Complex Figure Test: Recall) and visuo-spatial abilities (Leistungspruefsystem, LPS 9 and 10: Spatial imagination and embedded figures), but also of executive functions (Tower of Hanoi, Trail Making Test-B, semantic and figural fluency, LPS 4: Reasoning). In addition, the intra-individual ranges of neuropsychological test results in BPD patients were increased compared to those of healthy subjects. This finding might be due to a high degree of temporary stress that interferes with effective cognitive processing. Further research is needed to confirm the present results and to control for stress during the test procedure.

Functional MRI correlates of the recall of unresolved life events in borderline personality disorder.

BACKGROUND: Patients with borderline personality disorder (BPD) frequently report unresolved life events but it is still poorly understood, how these experiences are represented in the brain. Using functional magnetic resonance imaging (fMRI), the present study aimed at investigating the neural correlates of the recall of unresolved life events in patients with BPD and healthy controls. METHOD: Twenty female BPD patients and 21 healthy control subjects underwent fMRI. During measurement subjects recalled unresolved and resolved negative life events. Individual cue words were used to stimulate autobiographical memory. After scanning, subjects rated their emotional states during the recall of both types of memories. RESULTS: When contrasting unresolved and resolved life events, patients showed significant bilateral activation of frontotemporal areas including the insula, amygdala, and the anterior cingulate cortex, the left posterior cingulate cortex, right occipital cortex, the bilateral cerebellum and the midbrain. In healthy subjects, no differential brain activation was related to these conditions. The 2 x 2 factorial analysis (DeltaBPD - Deltacontrols) revealed similar results with bilateral activation of the frontal cortex including parts of the insula and of the orbitofrontal cortex, temporal activation including the amygdala, activation of the right occipital cortex, and parts of the cerebellum. Patients but not controls reported higher levels of anxiety and helplessness during the unresolved versus resolved memory condition. CONCLUSIONS: The activation of both, the amygdala and prefrontal areas, might reflect an increased effortful but insufficient attempt to control intensive emotions during the recall of unresolved life events in patients with BPD.

The consumption of cigarettes, coffee and sweets in detoxified alcoholics and its association with relapse and a family history of alcoholism.

Thirty male alcohol dependent inpatients without concurrent depressive disorder, 13 of them with a positive family history of alcohol dependence in a first degree relative (PFH), were questioned about their desire and consumption habits with respect to cigarettes, coffee, and sweets while on a three-week inpatient treatment after detoxification from alcohol. Six weeks after discharge from hospital, the patients were reassessed for relapse. Eleven patients (36.6%) had relapsed at follow-up. Relapsers were younger than abstainers. The days until relapse correlated negatively with intensity of desire to drink alcohol, desire to smoke cigarettes, and with a higher consumption of cigarettes. PFH patients did not relapse earlier but they had a stronger desire to drink coffee and eat sweets and had a higher coffee consumption.

Dexamethasone suppression test in borderline personality disorder--effects of posttraumatic stress disorder.

BACKGROUND: Divergent findings of hypothalamic-pituitary-adrenal (HPA) axis functioning in borderline personality disorder (BPD) may be caused by a different degree of comorbid posttraumatic stress disorder (PTSD), in which alterations of the HPA axis are well known. Here we investigate alterations of the HPA axis in BPD patients with and without comorbid PTSD compared to healthy controls. Considering previous findings current major depression (MDD) was taken into account as a confounding variable. METHODS: Apart from clinical assessment the 0.5 mg dexamethasone suppression test (DST) was performed in 21 female borderline patients and 23 healthy controls. RESULTS: Twelve BPD patients suffered from comorbid PTSD. Relative suppression (%) did not differ between healthy controls and the total BPD group, but BPD patients with comorbid PTSD showed increased suppression compared to those without. Comorbid MDD was not associated with suppression. CONCLUSIONS: Our results do not indicate a dysfunction of the HPA axis in BPD. However, comorbid PTSD seems to be associated with a relative hypersuppression in the 0.5 mg DST.

Proposal of a comprehensive clinical typology of alcohol withdrawal--a cluster analysis approach.

AIMS: To characterize the various courses of alcohol withdrawal. METHODS: The Alcohol Withdrawal Scale (AWS) was applied to 217 alcohol-dependent patients every 4 h till the symptoms of withdrawal had passed (until each of four consecutive scores were <3). Patients were medicated by a standardized treatment scheme according to AWS-scores. Hierarchical cluster analysis and discriminant analysis were applied. RESULTS: We found five clusters representing increasing severity of alcohol withdrawal. Each cluster is characterized by a combination of the two maximum subscores (vegetative and psychopathological subscore) and three additional psychopathological symptoms (anxiety, disorientation, and hallucination). In 18.4% of the patients, relevant symptoms were not observed (cluster 1), 18.9% developed mild or moderate vegetative symptoms only (cluster 2), and 40.6% additional anxiety (cluster 3). In cluster 4 (11.1%) the most frequent psychopathological symptoms were disorientation and anxiety but no hallucinations, which could be observed only in cluster 5 (11.1%). Discriminant analysis using the maximum subscores at the first day of treatment as independent variables correctly predicted 89.9% of the five clusters. CONCLUSIONS: Our findings support a model of alcohol withdrawal clustering along the two dimensions of vegetative and psychopathological severity. Furthermore, the AWS may be useful to predict the course of alcohol withdrawal already at the first day of treatment.

Continuous generation of single photons with controlled waveform in an ion-trap cavity system.

The controlled production of single photons is of fundamental and practical interest; they represent the lowest excited quantum states of the radiation field, and have applications in quantum cryptography and quantum information processing. Common approaches use the fluorescence of single ions, single molecules, colour centres and semiconductor quantum dots. However, the lack of control over such irreversible emission processes precludes the use of these sources in applications (such as quantum networks) that require coherent exchange of quantum states between atoms and photons. The necessary control may be achieved in principle in cavity quantum electrodynamics. Although this approach has been used for the production of single photons from atoms, such experiments are compromised by limited trapping times, fluctuating atom-field coupling and multi-atom effects. Here we demonstrate a single-photon source based on a strongly localized single ion in an optical cavity. The ion is optimally coupled to a well-defined field mode, resulting in the generation of single-photon pulses with precisely defined shape and timing. We have confirmed the suppression of two-photon events up to the limit imposed by fluctuations in the rate of detector dark counts. The stream of emitted photons is uninterrupted over the storage time of the ion, as demonstrated by a measurement of photon correlations over 90 min.

Posttraumatic stress disorder and fMRI activation patterns of traumatic memory in patients with borderline personality disorder.

BACKGROUND: Early traumatization and additional posttraumatic stress disorder are frequent in patients with borderline personality disorder (BPD). The purpose of this study was to investigate neural correlates of traumatic memory in BPD with and without posttraumatic stress disorder (PTSD) using functional magnetic resonance imaging (fMRI). METHODS: We studied 12 traumatized female patients BPD, 6 of them with and 6 without PTSD. According to an autobiographical interview key words (cues) were defined for traumatic and for negative but nontraumatic episodes. In a block-designed fMRI task patients recalled these episodes. Contrasts between trauma condition and nontrauma condition were analyzed. RESULTS: Analyses for all subjects revealed activation of orbitofrontal cortex areas in both hemispheres, anterior temporal lobes, and occipital areas. In the subgroup without PTSD, activation of orbitofrontal cortex on both sides and Broca's area predominated. In the subgroup with additional PTSD, we observed right more than left activation of anterior temporal lobes, mesiotemporal areas, amygdala, posterior cingulate gyrus, occipital areas, and cerebellum. CONCLUSIONS: Dependent on absence or presence of additional PTSD different neural networks seem to be involved in the traumatic memory of patients with BPD.

Adenomatosis del hepatocolédoco y ampulla / Adenomatosis of the hepatocholedocal duct ampulla

Se presentan 6 enfermos con obstrucción de la vía biliar extrahepática por adenomiosis. Esta patología se ubica en el grupo de los tumores epiteliais benignos, que obstruyen la vía biliar por la presencia intraparietal de cúmulos de conductos glandulares nodeados por un proceso inflamatorio crónico escleroso. Es una lesión de difícil diagnóstico clínico y operatorio donde la verdadera naturaleza la establece la anatomía patológica, que debe diferenciarlo del cáncer y páncreas aberrante

Implicancia de los pólipos en el cáncer rectocolónico / Involvement of the polyps in the rectocolonic neoplasms

Se presenta un estudio analítico sobre la importancia del cáncer en 454 enfermos portadores de adenomas simples con transformación carcinomatosa y adenocarcinomas, desarrollados en colon y recto. Los parámetros aportados por la clinica, los métodos de diagnóstico y patología, confirmaron que distintas formas de adenomas eran lesiones precancerosas. Sobre el total de pólipos estudiados se halló cáncer en el 21% de los casos; en los obtenidos por cirugía endoscópica en 6% y en aquellos con cáncer en el 33,9%. Cuando éste se encontró limitado al pólipo en el 24% (12 casos) existieron metástasis ganglionares, hecho más evidente cuanto mayor fuera el tamaño de la lesión. La cirugía endoscópica es un tratamiento preventivo del cáncer del colon. Para ello deben efectuarse con responsabilidad los métodos de diagnóstico y los estudios histopatológicos en un equipo multidisciplinario para seleccionar adecuadamente la terapéutica definitiva y la metodología del control alejado

Brote epidémico por Staphylococcus aureus en un área quirúrgica / Staphylococcus aureus infection out-break in a general surgery ward

Ante un aumento llamativo de las infecciones de heridas quirúrgicas ocurrido em mayo de 1983 en la I Cátedra de Cirugía, se determinó que la incidencia de las mismas era 12% en heridas limpias y 33% en limpias contaminadas. El germen causal fue el S. aureus en el 50% de las primeras y en el 83% de las segundas. La tasa de infección en el cuatrimestre anterior (enero-abril 1983) fue 6,4% y 14% respectivamente. A mediados de mayo de 1983 se comenzó programa de control que incluyó búsqueda de portadores en el personal, tratamiento de los mismos, disminución de los días promedio de internación y énfasis en las medidas generales de prevención de las infecciones quirúrgicas. Se encontró un índice de portación nasal de 39,3% en médios y 31,4% en enfermeras y mucamas, que fueron tratados con cefalexina + rifampicina. Se disminuyeron los días promedio de internación de 10.67 a 7.50 (30%). La incidencia de infección de la herida quirúrgica en junio, julio y agosto fue para heridas limpias, 6,2%, 8,3% y 10% y de heridas limpias costaminadas 14%, 4,3% y 6%, habiéndose observado un solo caso de infección por S. aureus en junio y ninguno en los meses siguientes. Al realizar el análisis estadístico de las series cronológicas se observó un cambio de gradiente en la recta de tendencia coincidente con las medidas adoptadas para el control del problema. Se destaca la importancia de la detección precoz, del tratamiento de los portadores nasales y de la reducción del tiempo de internación

Fistulas digestivas externas: oportunidad quirurgica / External gastrointestinal fistulas: surgical opportunity

Se comenta el tratamiento de 68 enfermos con fístulas gastroenterocutáneas observadas en un período de 13 años. Fueron comparados los tratamientos médicos nutricionales y los quirúrgicos realizados. Se concluye que existe un mayor número de fístula que cierran con tratamiento médico y que la cirugía mantiene sus indicaciones precisas, pero muchas veces queda postergada porque se insiste con la nutrición parenteral y enteral. Esta metodología posterga algunas intervenciones que practicadas en enfermos críticos acusan una morbimortalidad todavía elevada