HIV-Risk Behavior Among Adults with Opioid Use Disorder During 12 Months Following Pre-trial Detention: Results from a Randomized Trial of Methadone Treatment.

This was a three group randomized clinical trial of interim methadone and patient navigation involving 225 pre-trial detainees with opioid use disorder in Baltimore. The HIV Risk Assessment Battery (RAB) was administered at baseline (in jail), and at 6 and 12 months post-release. Generalized linear mixed model analyses indicated the condition × time interaction effect failed to reach significance (ps > .05) for both the drug risk and sex risk subscale scores. Therefore, findings suggest that there were no intervention effects on drug or sex risk behaviors. However, increased use of cocaine at baseline was associated with increases in drug- (b = .04, SE = .02) and sex-risk (b = .01, SE = .003) behaviors. These results suggest that interventions targeting cocaine use among pre-trial detainees may serve as a means of reducing HIV risk associated with drug- and sex-risk behaviors.Clinical Trials Registration: Clinicaltrials.gov NCT02334215.

A trial of implementation facilitation to increase timely admission to methadone treatment.

BACKGROUND: During the ongoing opioid epidemic, some Opioid Treatment Programs (OTPs) are unable to admit program applicants in a timely fashion. Interim methadone (IM) treatment (without routine counseling) is an effective approach to overcome this challenge when counseling capacity is inadequate to permit admissions within 14 days of request. It requires both federal and state approval and has been rarely utilized since its incorporation into the federal OTP regulations in 1993. METHODS: We evaluated the impact of Implementation Facilitation (IF) on OTPs providing timely admission to methadone treatment (i.e., within 14 days of request), adopting IM, and changing admissions procedures. IF included data collection on admission processes and an external facilitator who engaged OTP leadership, Local Champions through site visits, remote academic detailing, and feedback. Local Champions and State Opioid Treatment Authorities (SOTAs) participated in learning collaboratives. Using a modified stepped wedge design, six OTPs in four US states on the east and west coasts were randomly assigned to one of two clusters that staggered the timing of IF receipt. Study Phases included: Pre-Implementation, IF, and Sustainability. OTPs submitted data on treatment requests and admissions for 28 months (N = 3108 requests for treatment). RESULTS: Although none of the OTPs adopted IM, all six developed policies and procedures to enable its use. Some OTPs streamlined admissions processes prior to study launch and during the IF intervention. OTPs reduced admission delays over time, although there was substantial site heterogeneity. The IF Phase for the early cluster coincided with the onset of COVID-19, complicating the study. Rates of timely admission within 14 days of request were 56.2 % (Pre-Implementation), 55.8 % (IF), and 78.8 % (Sustainability). Compared to the Pre-Implementation Phase, the odds of timely admission were not significantly different during the IF Phase but significantly higher during the Sustainability Phase (OR = 2.35 [95 % CI = 1.34, 4.12]; p = 0.003). CONCLUSIONS: Committing to study participation and IF activities may have prompted some OTPs to change practices that improved timely admission. Attributing changes to IF should be done with caution considering study limitations. Data collection for the study spanned the COVID-19 pandemic, which complicates interpretation. TRIAL REGISTRATION: Clinicaltrials.gov registration # NCT04188977.

X chromosome gene methylation in peripheral lymphocytes from monozygotic twins discordant for scleroderma.

Scleroderma (SSc) is a rare connective tissue disease characterized by fibrosis, microvasculopathy and autoimmune features. The role of genetics is limited in SSc, as suggested by similar concordance rates in monozygotic and dizygotic twin pairs, while environmental factors may act through epigenetic changes, as demonstrated for specific genes. Further, sex chromosome changes have been reported in SSc and may explain the female preponderance. In the present study we compared the methylation profile of all X chromosome genes in peripheral blood mononuclear cells from monozygotic twins discordant (n=7) and concordant (n=1) for SSc. Methylated DNA immunoprecipitations from each discordant twin pair were hybridized to a custom-designed array included 998 sites encompassing promoters of all X chromosome genes and randomly chosen autosomal genes. Biostatistical tools identified sites with an elevated probability to be consistently hypermethylated (n=18) or hypomethylated (n=25) in affected twins. Identified genes include transcription factors (ARX, HSFX1, ZBED1, ZNF41) and surface antigens (IL1RAPL2, PGRMC1), and pathway analysis suggests their involvement in cell proliferation (PGK1, SMS, UTP14A, SSR4), apoptosis (MTM1), inflammation (ARAF) and oxidative stress (ENOX2). In conclusion, we propose that X chromosome genes with different methylation profiles in monozygotic twin pairs may constitute candidates for SSc susceptibility.

Disposition, behavioural and physiological effects of escalating doses of intravenously administered fentanyl to young foals.

REASONS FOR PERFORMING STUDY: Foal responses to a broader range of plasma fentanyl concentrations than currently reported are desirable to support (or not) clinical use. OBJECTIVES: To describe fentanyl plasma concentrations following an escalating i.v. fentanyl dosing schedule in foals aged 5-13 days and describe selected, associated dose- and time-related behavioural and physiological responses to plasma fentanyl concentration. STUDY DESIGN: Experimental. METHODS: Fentanyl was administered i.v. in an escalating fashion (2, 4, 8, 16 and 32 µg/kg bwt) at 10-min intervals. Blood samples were collected before and at selected times until 24 h post administration. Blood samples were analysed for fentanyl and metabolite concentrations and correlated with behavioural and physiological observations and selected blood analytes. RESULTS: Foals mostly appeared to be unaffected following 2 µg/kg bwt (1.09 ± 0.41 µg/l; average maximal plasma concentration) of fentanyl, but 6 of the 8 foals appeared to be sedated following 4 µg/kg bwt (3.07 ± 1.11 µg/l). Ataxia with increased locomotor activity, muscle rigidity and head pressing posture was observed in many foals at 8 (7.24 ± 3.22 µg/l) and 16 µg/kg bwt (17.4 ± 5.67 µg/l). All foals were heavily sedated after 32 µg/kg bwt (34.5 ± 10.3 µg/l); 3 of the 8 foals became recumbent. The average (± s.d.) terminal half-life following administration of the final dose was 44.2 ± 9.85 min. CONCLUSIONS: Behavioural and physiological responses to i.v. fentanyl in young foals are dose related. As with mature horses, the window of fentanyl plasma concentrations related to possible clinically desirable actions appears relatively narrow.

Effects of age on the pharmacokinetics and selected pharmacodynamics of intravenously administered fentanyl in foals.

REASONS FOR PERFORMING STUDY: The use of fentanyl is limited in adult horses, in part due to potential for central nervous system excitation. The pharmacokinetics and the plasma concentration-related behavioural actions of fentanyl have not been described for young foals. OBJECTIVES: The goal of the present study was to describe the pharmacokinetics and behavioural effects of fentanyl following administration to the same group of foals at 3 different ages. STUDY DESIGN: Experimental study in healthy foals. METHODS: Fentanyl was administered i.v. (4 µg/kg bwt) to a group of 9 foals on 3 separate occasions at 6­8, 20­22 and 41­42 days of age. Blood samples were collected prior to administration and at multiple times until 24 h post administration. Blood samples were analysed for fentanyl concentrations and pharmacokinetics determined at each age. Behavioural and physiological effects were also assessed. RESULTS: The average volume of distribution was 3.55, 1.53 and 1.82 l/kg bwt and clearance 50.2, 40.7 and 35.7 ml/min/kg bwt when foals were 6­8, 20­22 and 41­42 days of age, respectively. The elimination half-life was slightly prolonged (49.3 min) at 6­8 days relative to 20­22 and 41­42 days of age (25.8 and 33.7 min, respectively). The primary metabolite detected in blood samples was the same as for adult horses. While the onset and duration varied widely between foals, sedation was observed at all ages studied. CONCLUSIONS: Fentanyl appears to be consistently well tolerated following i.v. administration of 4 µg/kg bwt to foals ranging in age from 1 to 6 weeks. The results of this study support further study of fentanyl for clinical use in foals.

Pharmacokinetics and selected pharmacodynamics of cobalt following a single intravenous administration to horses.

Cobalt has been used by human athletes due to its purported performance-enhancing effects. It has been suggested that cobalt administration results in enhanced erythropoiesis, secondary to increased circulating erythropoietin (EPO) concentrations leading to improvements in athletic performance. Anecdotal reports of illicit administration of cobalt to horses for its suspected performance enhancing effects have led us to investigate the pharmacokinetics and pharmacodynamic effects of this compound when administered in horses, so as to better regulate its use. In the current study, 18 horses were administered a single intravenous dose of cobalt chloride or cobalt gluconate and serum and urine samples collected for up to 10 days post administration. Cobalt concentrations were measured using inductively coupled plasma mass spectrometry (ICP-MS) and pharmacokinetic parameters determined. Additional blood samples were collected for measurement of equine EPO concentrations as well as to assess any effects on red blood cell parameters. Horses were observed for adverse effects and heart rate monitored for the first 4 h post administration. Cobalt was characterized by a large volume of distribution (0.939 L/kg) and a prolonged gamma half-life (156.4 h). Cobalt serum concentrations were still above baseline values at 10 days post administration. A single administration of cobalt had no effect on EPO concentrations, red blood cell parameters or heart rate in any of the horses studied and no adverse effects were noted. Based on the prolonged gamma half-life and prolonged residence time, regulators should be able to detect administration of a single dose of cobalt to horses.

Evaluation of a patient education program for chronic obstructive pulmonary disease.

An audiovisual instructional program for patients with chronic obstructive pulmonary disease was evaluated in 65 patients with this disease and 20 patients without lung disease. We found that the program was successful in increasing the factual knowledge about chronic obstructive pulmonary disease, with the attainment of mean scores of 88 and 95% on postteaching tests. Patients with varying educational backgrounds achieved similar gains in knowledge.

The Student Response System. A 5-year Mayo Medical School Experience.

The Student Response System is a commercially available electronic communication system applicable to many teaching and testing situations. At rather short intervals during a programmed course, the instructor projects on a screen multiple-choice questions that the student should have learned to answer during one or two previous teaching steps. Correct and incorrect responses are indicated on a panel on the desk of the instructor. If students fail to give the correct answer, the teaching step is repeated. Recurrent incorrect answers indicate that explanations had been inappropriate or that test slides were poorly designed. Thus, the system allows the instructor to monitor his own performance. Students are kept alert and attention spans are prolonged; communication is increased and personal embarrassment is minimized. Only the instructor has access to the individual student's response. Most learning takes place in the classroom rather than during subsequent private study. This system is quite versatile and offers potential uses hitherto untested in medical education at all levels.

Testing as a component of continuing education programs: evaluation of conference presentations by this method.

As a means of evaluating the effect of each presentation at a national medical conference and of the meeting as a whole, the scheduled lecturers were asked to supply the testers with several questions that summarized the most important points of their talks. Audience participants at the meeting were given tests drawn from these questions--one test before the beginning of the meeting, and another at the end. The results were compared for the answers to each lecturer's 3-question group, and for the complete tests. All scores were better at the end than at the beginning of each lecture. A follow-up survey of the attitudes of participants showed a positive reaction to the use of such testing at future meetings.

Transesophageal echocardiography.

Two-dimensional transesophageal echocardiography generally has superior sensitivity and image quality compared with precordial echocardiography. Its unique anatomic perspective posterior to the heart often provides important clinical information not obtainable by other imaging approaches and technologies. It is particularly useful in the diagnosis of mitral valve disease, left atrial masses, endocarditis and its sequelae, and aortic dissections. It is also useful for examination of the left main coronary artery, left ventricular outflow tract, atrial and ventricular septa, and congenital defects. In addition to its application as a diagnostic tool in conscious patients, it can be employed intraoperatively to evaluate and guide surgical intervention. Detection of ventricular wall motion abnormalities by transesophageal echocardiography has been shown to be the most sensitive indicator of myocardial ischemia available in the clinical setting. It has potential for wide application for safely monitoring left ventricular function in patients in intensive care or under anesthesia.

Quantitative immunoblotting with fusion proteins.

The development of vaccines against HIV-1 is currently hindered by incomplete understanding of correlates of protective immunity (1-3). Experiments are necessary to measure immune responses in sufficiently fine detail that specific protective responses can be discerned from those that are irrelevant or harmful. When vaccines are tested as potential therapeutics, it is further necessary to differentiate induced responses from those associated with the infection itself. Measurement of humoral responses to well-defined antigens particularly lends itself to detailed mapping (4). Small synthetic antigens may be used in ELISA or BIAcore assays (5-7). Larger antigens, such as fusion proteins, may require assays with more specificity, because of the possibility of immune-reactive contaminants. A particularly useful technique in this context is immunoblotting, because contaminating antigens are separated away during the electrophoresis step (8,9). In the authors' laboratory, immunoblots employing fusion proteins of HIV-1 envelope sequences have been successfully used to quantitate new responses post immunization with a vaccine candidate in spite of a substantial baseline response to the whole antigen (10,11). The same technique was used to measure responses against vaccine candidates in small animal models (12,13).

Professional development: clinician to academician.

Drawing on literature from other professions, this paper identifies factors that occupational therapists should consider when making the transition from clinician to academician. It describes the following four stages of a professional career: apprentice, colleague, mentor, and sponsor. Five academic stages of faculty development are also presented. In addition, the work life of a faculty member is delineated.

Professional involvement in sexuality counseling for patients with spinal cord injuries.

A national survey was conducted to determine how occupational therapists and rehabilitation nurses conduct sexuality counseling in practice settings with spinal cord-injured patients. A review of the literature and results from the survey demonstrated a high priority concern for sexuality counseling in the total rehabilitation of the spinal cord-injured patient; however, many of the professionals surveyed did not conduct sexuality counseling as part of their job. This study provides data comparing the sexuality counseling approach taken by these two disciplines and identifies ways to eliminate the incongruities between recommendations made in the literature and actual clinical practice.

A model for establishing occupational therapy and physical therapy services in the public schools.

One procedure for the establishment of therapists in public schools and on management and administration teams in the State Department of Public Instruction, Division for Exceptional Children is discussed. A significant aspect of the procedure is a model for a working relationship between the Division for Exceptional Children and the Occupational Therapy and Physical Therapy Divisions in the Department of Medical Allied Health Professions in a School of Medicine.

Coping strategies used by occupational therapy students during fieldwork: an exploratory study.

This exploratory study examined the coping strategies and perceptions of 24 graduate students in occupational therapy who were participating in their second Level II fieldwork experience. The instruments used were the revised Ways of Coping Checklist (WCCL) (Vitaliano, Russo, Carr, Maiuro, & Becker, 1985) and a questionnaire developed by the authors. The results showed that of the five coping scales of the WCCL, the students used the Problem-Focused and Seeks Social Support strategies more than the Blamed Self, Wishful Thinking, and Avoidance strategies. Most of the students perceived the fieldwork experience as important, controllable, and stressful, but not disruptive to their lives.

Student coping strategies and perceptions of fieldwork.

A questionnaire, the revised Ways of Coping Checklist, was sent to all professional (entry-level) graduate students in the United States in one academic year during their second fieldwork level II experience to determine what coping strategies they used during their fieldwork experience. Information was also gathered regarding their perceptions of this clinical experience. Responses from 101 students showed that they used Problem-Focused and Seeks Social Support strategies more than Wishful Thinking, Blamed Self, or Avoidance strategies. More than half of the students found the experience to be stressful, and almost all agreed that it was important. Most agreed that they had control over their present circumstances in the fieldwork experience.

Use of taxonomies to sequence clinical objectives.

This paper describes the use of four educational taxonomies in establishing a task grid for guiding and determining sequential learning opportunities and activities for the developmentally delayed child and for treatment planning for team members working with the child. It describes a three-dimensional grid that includes learners, areas of learning, and levels of learning. To clarify the use of this model, the grid has been applied to feeding intervention with the delayed child. Use of the task grid suggests three factors are needed in intervention with the developmentally delayed child: 1. objectives should be stated for all domains of learning since learning occurs concurrently in different areas; 2. activities should be sequenced not only for the child but also for all those directly involved with the child, since all are involved in the learning process; and 3. analytical behavior should be stimulated in the therapist so that theory-based practice can be realized.

Administrative patterns in curriculum-clinic interactions.

A questionnaire was sent to directors of occupational therapy curricula and faculty members, to directors of occupational therapy clinics and clinicians, to deans of medical schools, and to hospital administrators in order to determine the professional and administrative relationships between occupational therapy academic programs and clinical programs. Results of the survey, analyzed by groups, indicated that informal relationships were prevalent, whereas other relationships were poorly delineated. Strengths and weaknesses of formal and informal relationships are presented. Finally, a model for interaction is proposed.

Effectiveness of recruitment and information techniques in occupational therapy.

A national survey was conducted to determine how occupational therapists became interested in the field. Results from the study demonstrated that personal contact was the most effective technique for creating an interest in occupational therapy. However, books, magazines, aide and volunteer jobs, guidance counselors, and career days were adjuncts to the recruitment process. This study provides data concerning previous productive means that have been used in recruitment and suggests specific actions for future recruitment.

Analysis of the Development Test of Visual Perception and the Motor-Free Visual Perception Test.

To identify children with learning problems and to compare test results, 28 kindergarten children were tested with the Developmental Test of Visual Perception and the Motor-free Visual Perception Test. The tests identified some children already noted by the teacher to exhibit characteristics of learning difficulty, failed to confirm the teacher's judment in others, and identified some children with previously undetected difficulties. Basic differences in the two tests are reported.