Scopes of practice for advanced practice nursing and advanced practice midwifery in Kenya: A gap analysis.

BACKGROUND: There is increasing global evidence on the impact of advanced nursing and midwifery practitioners, and Kenya's healthcare system has an excellent opportunity to develop scopes of practice and other regulatory frameworks for the integration of these roles. OBJECTIVE: The primary purpose of this gap analysis was to explore the existing evidence on opportunities and threats toward the integration of the advanced practice nursing (APN) and advanced practice midwifery (APM) roles in Kenya's healthcare system. METHODS: The study team conducted a structured electronic database search of PubMed, CINAHL, Scopus, EBSCOhost Academic Search Complete, and PsycINFO to retrieve articles and credible websites for reports highlighting the opportunities and threats toward the integration of the APN and APM roles in Kenya's healthcare systems. The retrieved articles were screened for relevance and synthesized for reporting using the traditional literature review approach. RESULTS: The Kenya Health Policy Framework 2014-2030, growing population needs, and implementation of universal health coverage provide an opportunity to harness and leverage advanced practice roles in nursing and midwifery. There is also momentum to develop advanced practice because of strategic alliances and global evidence showing the contributions and quality of services offered by advanced practice nurses and advanced practice midwives. However, lack of financial support, structural challenges, and lack of national policies, regulations, and legislation continue to obstruct progress. CONCLUSION AND IMPLICATIONS FOR NURSING POLICY: Developing scopes of practice for APN and APM in Kenya will benefit the professions, the country's healthcare delivery system, and the population. Achieving universal health coverage depends on a health workforce trained and practicing at optimal levels in tandem with education and training to deliver quality care.

Racism, colonialism and the implications for nursing scholarship: A discussion paper.

AIM: A critical discussion of the intersections between racism and colonialism as social determinants of health and explore how these discriminatory ideologies shape nursing inquiry. DESIGN: Discussion paper. DATA SOURCES: A review of pertinent discourse on racism and colonialism in nursing from 2000 to 2022. IMPLICATIONS FOR NURSING: The failure to address health inequity plaguing racialized and marginalized populations locally and globally affects all groups, as illustrated in the COVID-19 pandemic. Racism and colonialism are inextricably linked, creating potent forces that influence nursing scholarship and adversely affect the health of a culturally and racially diverse society. Power differentials exist within and between countries creating structural challenges that lead to inequitable distribution of resources and othering. Nursing cannot be abstracted from the sociopolitical context in which it exists. There have been calls to address the social drivers that influence the health of the communities. More still needs to be done to support an antiracist agenda and decolonize nursing. CONCLUSION: Nurses, as the largest healthcare workforce, can be critical in addressing health disparities. However, nurses have failed to eliminate racism within their ranks, and essentialism ideology has been normalized. A multidimensional approach that includes interventions aimed at nursing education, direct patient care, community health, nursing organizations and policy is needed to address problematic nursing discourse rooted in colonialism and racism ideologies. Since knowledge generated from scholarship informs nursing education, practice and policy, it is imperative to implement antiracist policies that eliminate racist assumptions and practices from nursing scholarship. NO PATIENT OR PUBLIC CONTRIBUTION: The paper is a discursive paper using pertinent nursing literature. IMPACT: For nursing to attain its potential as a leader in healthcare, standards of scientific vigour should be embedded within history, culture and politics. Recommendations are provided on possible strategies to identify, confront and abolish racism and colonialism in nursing scholarship.

Nursing and midwifery education, regulation and workforce in Kenya: A scoping review.

AIM: To explore contextual literature on nursing and midwifery education, regulation and workforce in Kenya to develop an understanding of the current state and inform opportunities to strengthen the nursing and midwifery professions. INTRODUCTION: Kenya has yet to achieve the minimum nursing and midwifery workforce threshold, despite the exponential increase in population and epidemiologic disease transitions. BACKGROUND: There are glaring health gaps and inequities in sub-Saharan African countries. Health systems are evolving into complex and costly utilities, increasing the demand for nurses and midwives. It is, therefore, necessary to re-examine systems that educate, deploy and retain the nursing workforce, especially given the ongoing COVID-19 pandemic and increase in non-communicable diseases. METHODS: This scoping review was guided and reported following the PRISMA-ScR guidelines. Four electronic databases (PubMed, Scopus, CINAHL and Web of Science) were probed for relevant studies conducted in Kenya between 1963 and 2020. The search was supplemented using Google Scholar. Findings from selected studies were extracted and analysed thematically. RESULTS: Of the 238 retrieved studies, 37 were included in this review: 10 articles on nursing and midwifery education, 11 on regulation and 16 on the workforce. DISCUSSION: There have been changes in regulation and an increase in nursing and midwifery enrolment and graduates. However, maldistribution and shortage of nurses and midwives persist. CONCLUSIONS: Kenya's nursing and midwifery professions have undergone significant changes to meet the demand for a skilled workforce. However, the shortage of qualified and specialised nurses and midwives persists. Moreover, this shortage is exacerbated by underinvestment, outmigration and a need for more reforms to expand the nursing and midwifery workforce. IMPLICATION FOR NURSING AND MIDWIFERY POLICY: Investment in nurse and midwifery education, mentorship and legislation is needed to build the capacity of the profession to provide quality health services. Several nursing and midwifery policy changes utilising a multipronged approach involving stakeholders' collaboration are suggested to address the bottlenecks from education to deployment.

Duty versus distributive justice during the COVID-19 pandemic.

The COVID-19 pandemic exposed vulnerabilities in inadequately prioritized healthcare systems in low- and middle-income countries such as Kenya. In this prolonged pandemic, nurses and midwives working at the frontline face multiple ethical problems, including their obligation to care for their patients and the risk for infection with severe acute respiratory syndrome coronavirus 2. Despite the frequency of emergencies in Africa, there is a paucity of literature on ethical issues during epidemics. Furthermore, nursing regulatory bodies in African countries such as Kenya have primarily adopted a Western code of ethics that may not reflect the realities of the healthcare systems and cultural context in which nurses and midwives care for patients. In this article, we discuss the tension between nurses' and midwives' duty of care and resource allocation in the context of the COVID-19 pandemic. There is an urgent need to clarify nurses' and midwives' rights and responsibilities, especially in the current political setting, limited resources, and ambiguous professional codes of ethics that guide their practice.

Neuroendocrine effects of naltrexone versus nalmefene in humans.

OBJECTIVE: Naltrexone and nalmefene are approved for the treatment of alcohol use disorders, in different countries. Naltrexone is also approved for the treatment for opioid use disorders, most recently in a depot formulation. These compounds target primarily µ(mu)- and κ(kappa)-opioid receptor systems, which are involved in the downstream neurobiological effects of alcohol and in the modulation of neuroendocrine stress systems. The study objective was to compare the neuroendocrine effects of naltrexone and nalmefene on adrenocorticotropic hormone (ACTH), cortisol, and prolactin, in normal volunteers. METHOD: Adult normal volunteers (n = 11 male and n = 9 female) were studied in a stress-minimized inpatient setting on three consecutive days, after intravenous saline, naltrexone HCl (10 mg), or nalmefene HCl (10 mg), in fixed order. ACTH, cortisol, and prolactin were analyzed pre-injection and up to 180 min post-injection. RESULTS: Naltrexone and nalmefene caused elevations in ACTH and cortisol compared with saline. Nalmefene had a greater effect on ACTH and cortisol, compared with naltrexone. Both compounds also caused elevations in prolactin in males (females were not examined, due to the influence of menstrual cycle on prolactin). CONCLUSIONS: This study suggests that both nalmefene and naltrexone have effects potentially due to κ-partial agonism in humans, as well as antagonist effects at µ-receptors.

Maternal and newborn care during the COVID-19 pandemic in Kenya: re-contextualising the community midwifery model.

Peripartum deaths remain significantly high in low- and middle-income countries, including Kenya. The COVID-19 pandemic has disrupted essential services, which could lead to an increase in maternal and neonatal mortality and morbidity. Furthermore, the lockdowns, curfews, and increased risk for contracting COVID-19 may affect how women access health facilities. SARS-CoV-2 is a novel coronavirus that requires a community-centred response, not just hospital-based interventions. In this prolonged health crisis, pregnant women deserve a safe and humanised birth that prioritises the physical and emotional safety of the mother and the baby. There is an urgent need for innovative strategies to prevent the deterioration of maternal and child outcomes in an already strained health system. We propose strengthening community-based midwifery to avoid unnecessary movements, decrease the burden on hospitals, and minimise the risk of COVID-19 infection among women and their newborns.

Reexamining the use of race in medical algorithms: the maternal health calculator debate.

The concept of race is prevalent in medical, nursing, and public health literature. Clinicians often incorporate race into diagnostics, prognostic tools, and treatment guidelines. An example is the recently heavily debated use of race and ethnicity in the Vaginal Birth After Cesarean (VBAC) calculator. In this case, the critics argued that the use of race in this calculator implied that race confers immutable characteristics that affect the ability of women to give birth vaginally after a c-section. This debate is co-occurring as research continues to highlight the racial disparities in health outcomes, such as high maternal mortality among Black women compared to other racial groups in the United States. As the healthcare system contemplates the necessity of utilizing race-a social and political construct, to monitor health outcomes, it has sparked more questions about incorporating race into clinical algorithms, including pulmonary tests, kidney function tests, pharmacotherapies, and genetic testing. This paper critically examines the argument against the race-based Vaginal Birth After Cesarean (VBAC) calculator, shedding light on its implications. Moreover, it delves into the detrimental effects of normalizing race as a biological variable, which hinders progress in improving health outcomes and equity.

Surviving Covid-19 Diagnosis Among Registered Nurses: Reactions, Consequences, and Coping Mechanisms.

Background: To mitigate the spread of Covid-19, nurses infected with the virus were required to isolate themselves from their families and community. Isolated patients were reported to have experienced mental distress, posttraumatic stress disorder symptoms, and suicide. Though studies have reported the psychological impact of the Covid-19 pandemic, less is known about the lived experiences of nurses who survived Covid-19 infection in sub-Saharan Africa. Methods: A descriptive phenomenological approach was used to study the lived experiences of registered nurses who survived Covid-19 disease. In-depth interviews were conducted among nurses diagnosed with Covid-19 from two hospitals in Kenya between March and May, 2021. Purposive and snowball sampling were used to recruit registered nurses. Data were analyzed using Giorgi's steps of analysis. Results: The study included ten nurses between 29 and 45 years of age. Nurses' experiences encompassed three themes: diagnosis reaction, consequences, and coping. Reactions to the diagnosis included fear, anxiety, and sadness. The consequence of the diagnosis and isolation was stigma, isolation, and loneliness. Nurses coping mechanisms included acceptance, creating routines, support, and spirituality. Conclusion: Our findings aid in understanding how nurses experienced Covid-19 infection as patients and will provide evidence-based content for supporting nurses in future pandemics. Moreover, as we acknowledge the heroic contribution of frontline healthcare workers during the Covid-19 pandemic, it is prudent to recognize the considerable occupational risk as they balance their duty to care, and the risk of infection to themselves and their families.

Knowledge, Attitudes, and Preparedness for Managing Pregnant and Postpartum Women with COVID-19 Among Nurse-Midwives in Kenya.

Introduction: Globally, maternal morbidity and mortality have increased during the COVID-19 pandemic. Given the high burden of maternal and neonatal mortality in Kenya prior to COVID-19, front line health workers, including nurse-midwives, must be competent to ensure continued quality maternal services. Knowledge and awareness of COVID-19 transmission influence nurse-midwives risk perception and ability to implement prevention strategies. Objective: We examined nurse-midwives' knowledge, attitudes, and preparedness in managing pregnant and postpartum women with COVID-19 in Kenya. Methods: A cross-sectional online survey was conducted among 118 nurse-midwives between July 2020 and November 2020. A 31-item survey comprising 15 knowledge, 11 attitude, and five preparedness questions was administered using SurveyMonkey. A link to the survey was distributed among nurse-midwives via email. Multiple logistic regression analysis was used to assess associations between the variables. A p-value <.05 was considered statistically significant. Results: Eighty-five participants were included in the final analysis (response rate 72%). Most participants were female (n = 69, 81.2%), 52.9% (n = 45) worked in labor wards, and 57.6% (n = 49) worked in rural hospitals. Overall, 71% (n = 57) of participants had sufficient knowledge about managing COVID-19 in pregnant and postpartum women. However, only 63% were willing to receive COVID-19 vaccination. Nurse-midwives working in urban areas were 3.7 times more likely to have positive attitudes than those in rural areas (odds ratio 3.724, 95% confidence interval 1.042-13.31; p = .043). Conclusion: Nurse-midwives' responses to the Kenyan government's COVID-19 guidelines for managing and caring for pregnant women were inconsistent. Continued professional development for nurse-midwives is important to ensure they stay abreast of evolving COVID-19 guidelines for maternal health. Our findings also suggest vaccine hesitancy may be a hurdle for ongoing COVID-19 vaccination.

Characteristics and outcomes of patients with an unscheduled return visit within 72 hours to the Paediatric Emergency Centre at a Private Tertiary Referral Hospital in Kenya.

INTRODUCTION: Patients' unscheduled return visits (URVs) to the paediatric emergency Centre (PEC) contribute to overcrowding and affect health service delivery and overall quality of care. This study assessed the characteristics and outcomes of paediatric patients with URVs (within 72 hours) to the PEC at a private tertiary hospital in Kenya. METHODS: We conducted a retrospective chart review of all URVs within 72 hours among paediatric patients aged ≤15 years between 1 July and 31 December 2018 at the tertiary hospital in Nairobi, Kenya. RESULTS: During the study period, 1.6% (n=172) of patients who visited the PEC returned within 72 hours, with 4.7% revisiting the PEC more than once. Patients' median age was 36 months (interquartile range: 42 months); over half were male (51.7%), 55.8% were ambulatory and 84.3% were insured. In addition, 21% (n=36) had chronic diseases and 7% (n=12) had drug allergies. Respiratory (59.5%) and gastrointestinal (21.5%) tract infections were the most common diagnoses. Compared with the first visit, more patients with URVs were classified as urgent (1.7% vs. 5.2%) and were non-ambulatory (44.2% vs. 49.5%, p=<0.001); 18% of these patients were admitted. Of these 58% were male, 83.9% were aged 0-5 years, 12.9% were classified as urgent, 64.5% had respiratory tract infections and 16.1% had gastrointestinal tract infections. Being admitted was associated with patient acuity (p=0.004), laboratory tests (p=<0.001) and ambulatory status (p=0.041). CONCLUSION: The URV rate is low in our setting. Patients who returned to the PEC within 72 hours tended to be male, under 5 years old and insured. Many were non-urgent cases with diagnoses of respiratory and gastrointestinal tract infections. The findings suggest that some URVs were necessary and may have contributed to better care and improved outcomes while others highlight a need for effective patient education and comprehensive initial assessment.

Prevalence and Effect of Workplace Violence against Emergency Nurses at a Tertiary Hospital in Kenya: A Cross-Sectional Study.

INTRODUCTION: Workplace violence (WPV) is a major occupational and health hazard for nurses. It affects nurses' physical and psychological well-being and impacts health service delivery. We aimed to assess the prevalence and describe the consequences of WPV experienced by nurses working in an emergency department in Kenya. METHODS: We conducted a descriptive cross-sectional study among emergency nurses at one of the largest tertiary hospitals in Kenya. We collected data using a structured questionnaire adapted from the 'WPV in the Health Sector, Country Case Studies Research Instruments' questionnaire. We described the prevalence and effects of WPV using frequencies and percentages. RESULTS: Of the 82 participating nurses, 64.6% were female, 57.3% were married and 65.8% were college-educated (65.8%). Participants' mean age was 33.8 years (standard deviation: 6.8 years, range: 23-55). The overall lifetime prevalence of WPV was 81.7% (n = 67, 95% confidence interval [CI]: 71.6%-88.8%) and the 1-year prevalence was 73.2% (n = 63, 95% CI: 66.3-84.8%). The main WPV included verbal abuse, physical violence, and sexual harassment. Most incidents were perpetrated by patients and their relatives. No action was taken in 50% of the incidents, but 57.1% of physical violence incidents were reported to the hospital security and 28.6% to supervisors. Perpetrators of physical violence were verbally warned (42.9%) and reported to the hospital security (28.6%). CONCLUSION: Workplace violence is a significant problem affecting emergency nurses in Kenya. Hospitals should promote workplace safety with zero-tolerance to violence. Nurses should be sensitised on WPV to mitigate violence and supported when they experience WPV.

Exploring perspectives on antimicrobial stewardship: a qualitative study of health managers in Kenya.

BACKGROUND: Antimicrobial resistance is a significant public health concern with the establishment of antimicrobial stewardship in hospitals being increasingly obligatory. Perspectives and insights of health managers on antimicrobial stewardship (AMS), complementary health services and building blocks are imperative towards implementation of robust AMS programs. This study aimed to understand perspectives of hospital managers on AMS and identify areas of management engagement while addressing potential blockades to change. METHODS: A cross-sectional, qualitative, multicenter study was conducted in three hospitals in Kenya. Key-informant interviews on perspectives on AMS were administered to hospital managers. Qualitative data was captured using audio tapes and field notes, transcribed and managed using NVivo 12 software. An iterative process was used to develop the thematic framework and updated in two rounds of iteration analysis. Analysis charts for each emergent theme were developed and categorized across all participants. RESULTS: Perspectives on AMS are described in five thematic categories; Importance of antimicrobial stewardship and the role of medicines and therapeutics committee, availability of antimicrobial formulary and usage surveillance systems, laboratory competency and recommendations for infection prevention and management, educational resources and communications channels available, building blocks and low-lying fruits for Antimicrobial Stewardship Committees. The role of stewardship collaboration in diagnosis and antimicrobial prescription was alluded to with managers indicating a growing rise in occurrence of antimicrobial resistance. There lacked contextualized, hospital specific antimicrobial formulary and adequate laboratory competency. Staff training and communication channels were available in varying capacity across the three hospitals. Building blocks identified include medicines and therapeutics committee, education, and training platforms (Continuous Medical Education and Continuous Professional Development activities) and hospital leadership commitment. CONCLUSIONS: The practice of antimicrobial stewardship is not implemented and well developed as demonstrated by lack of core AMS complementary health services. However, the health managers are aware of the fundamental importance of antimicrobial stewardship programs and the vast benefits of implementation and institutionalization of AMS to hospitals and their clients. The findings underpin the importance of understanding and incorporating perspectives of health managers on existing contextual mechanisms that can be leveraged on to establish robust AMS programs in the fight against antimicrobial resistance.

Reorienting Nurturing Care for Early Childhood Development during the COVID-19 Pandemic in Kenya: A Review.

In Kenya, millions of children have limited access to nurturing care. With the Coronavirus disease 2019 (COVID-19) pandemic, it is anticipated that vulnerable children will bear the biggest brunt of the direct and indirect impacts of the pandemic. This review aimed to deepen understanding of the effects of COVID-19 on nurturing care from conception to four years of age, a period where the care of children is often delivered through caregivers or other informal platforms. The review has drawn upon the empirical evidence from previous pandemics and epidemics, and anecdotal and emerging evidence from the ongoing COVID-19 crisis. Multifactorial impacts fall into five key domains: direct health; health and nutrition systems; economic protection; social and child protection; and child development and early learning. The review proposes program and policy strategies to guide the reorientation of nurturing care, prevent the detrimental effects associated with deteriorating nurturing care environments, and support the optimal development of the youngest and most vulnerable children. These include the provision of cash transfers and essential supplies for vulnerable households and strengthening of community-based platforms for nurturing care. Further research on COVID-19 and the ability of children's ecology to provide nurturing care is needed, as is further testing of new ideas.

Are trait impulsivity and exposure to cannabis or alcohol associated with the age of trajectory of cocaine use? A gender-specific dimensional analysis in humans with cocaine dependence diagnosis.

Cocaine use disorders (CUD) cause major morbidity and optimized prevention efforts are critical. It is unclear if trait impulsivity and exposure to cannabis or alcohol are associated with age trajectory of cocaine use (e.g., age of onset of heaviest use, or time of escalation), or with vulnerability to develop a CUD. This is an observational study with volunteers (≥ 18 years old), from a metropolitan area. The sample (n = 1,010) included: n = 360 normal volunteers, n = 438 with cocaine dependence (CD) diagnoses, and n = 212 with other addictive diseases. Trait impulsivity was examined with BIS-11 scores. Maximal self-exposure to cannabis, alcohol, and cocaine were characterized dimensionally with Kreek-McHugh-Schluger-Kellogg (KMSK) scales. Time of escalation was defined as the interval between age of first use and age of onset of heaviest use. Onset of maximal use of cannabis (median age = 17) and alcohol (median age = 21) preceded that of cocaine (median age = 27), in volunteers with CD. Multivariate Cox regressions in volunteers with CD show that increasing self-exposure to cannabis was a predictor of earlier onset of heaviest use of cocaine. Also, more rapid time of escalation of alcohol was a predictor of more rapid time of escalation of cocaine. A multiple logistic regression shows that increasing self-exposure to cannabis or alcohol was a positive predictor of odds of CD diagnosis. Trait impulsivity and gender were not significant predictors in these multivariate analyses. This study shows that aspects of adolescent exposure to nonmedical cannabis and alcohol are predictors of early onset of CUD, and may be potentially targeted for prevention efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Repeated Administration of Opra Kappa (LY2456302), a Novel, Short-Acting, Selective KOP-r Antagonist, in Persons with and without Cocaine Dependence.

This corrects the article DOI: 10.1038/npp.2017.205.

Repeated Administration of Opra Kappa (LY2456302), a Novel, Short-Acting, Selective KOP-r Antagonist, in Persons with and without Cocaine Dependence.

The κ-opioid receptor (KOP-r) system and its endogenous ligands, the dynorphins, are involved in the neurobiological regulation of addictive states, and of mood. There are limited data on the impact of selective KOP-r antagonism in humans on basic biobehavioral functions, or on addictive diseases and mood disorders. Previously studied selective KOP-r antagonists have unusual pharmacodynamic and pharmacokinetic properties (slow development of KOP-r selectivity, extremely long duration of action) that limit translation to human studies. A recently developed selective KOP-r-antagonist, Opra Kappa (LY2456302; CERC-501), has medication-like duration of action, oral bioavailability, and target engagement. The current study is the first investigation of the effects of a KOP-r-antagonist in cocaine-dependent persons in comparison with normal volunteers. In a stress-minimized inpatient setting, we determined the neuroendocrine and neurobehavioral effects of repeated administration of an active dose of Opra Kappa (10 mg p.o. daily, four consecutive days in comparison with an initial baseline day). Healthy volunteers (n=40), persons diagnosed with cocaine dependence in early abstinence (<2 months, EACD) (n=23), and drug-free former cocaine-dependent persons (7-month to 25-year abstinence, DFFCD) (n=7) were studied, with measurements including circulating neuroendocrine hormones, affect, and, in cocaine-dependent persons, cocaine craving. Modest adverse events related to Opra Kappa included pruritus, observed in a subset of individuals. No significant change was observed in serum prolactin levels following Opra Kappa administration, but modest increases in circulating adrenocorticotropic hormone and cortisol were observed. No significant changes were noted in measures of depression or cocaine craving in this stress-minimized setting. Overall, these studies demonstrate that effects of 10 mg Opra Kappa are largely consistent with those predicted for a selective KOP-r antagonist. This medication regimen was tolerable, and is therefore feasible for further studies in cocaine-dependent persons.

Re-evaluation of the KMSK scales, rapid dimensional measures of self-exposure to specific drugs: Gender-specific features.

BACKGROUND: The Kreek-McHugh-Schluger-Kellogg (KMSK) scales provide a rapid assessment of maximal self-exposure to specific drugs and can be used as a dimensional instrument. This study provides a re-evaluation of the KMSK scales for cannabis, alcohol, cocaine, and heroin in a relatively large multi-ethnic cohort, and also the first systematic comparison of gender-specific profiles of drug exposure with this scale. METHODS: This was an observational study of n = 1,133 consecutively ascertained adult volunteers. The main instruments used were the SCID-I interview (DSM-IV criteria) and KMSK scales for cannabis, alcohol, cocaine, and heroin. RESULTS: Participants were 852 volunteers (297 female) with specific DSM-IV abuse or dependence diagnoses, and 281 volunteers without any drug diagnoses (154 female). Receiver operating characteristic (ROC) curves were calculated for concurrent validity of KMSK scores with the respective DSM-IV dependence diagnoses. The areas under the ROC curves for men and women combined were 99.5% for heroin, 97% for cocaine, 93% for alcohol, and 85% for cannabis. Newly determined optimal KMSK "cutpoint" scores were identical for men and women for cocaine and heroin dependence diagnoses, but were higher in men than in women, for cannabis and alcohol dependence diagnoses. CONCLUSIONS: This study confirms the scales' effectiveness in performing rapid dimensional analyses for cannabis, alcohol, cocaine, and heroin exposure, in a cohort larger than previously reported, with "cutpoints" changed from initial determinations, based on this larger sample. The KMSK scales also detected gender differences in self-exposure to alcohol and cannabis that are associated with the respective dependence diagnoses.