HIV rapid testing in substance abuse treatment: implementation following a clinical trial.

The Substance Abuse Mental Health Services Administration has promoted HIV testing and counseling as an evidence-based practice. Nevertheless, adoption of HIV testing in substance abuse treatment programs has been slow. This article describes the experience of a substance abuse treatment agency where, following participation in a clinical trial, the agency implemented an HIV testing and counseling program. During the trial, a post-trial pilot, and early implementation the agency identified challenges and developed strategies to overcome barriers to adoption of the intervention. Their experience may be instructive for other treatment providers seeking to implement an HIV testing program. Lessons learned encompassed the observed acceptability of testing and counseling to clients, the importance of a "champion" and staff buy-in, the necessity of multiple levels of community and agency support and collaboration, the ability to streamline staff training, the need for a clear chain of command, the need to develop program specific strategies, and the requirement for sufficient funding. An examination of costs indicated that some staff time may not be adequately reimbursed by funding sources for activities such as adapting the intervention, start-up training, ongoing supervision and quality assurance, and overhead costs.

Making the transition: the role of helical CT in the evaluation of potentially acute thoracic aortic injuries.

OBJECTIVE: The purpose of this study was to show that helical CT could be used at our center in lieu of routine aortography to examine patients who have had serious blunt chest trauma. We also wanted to assess the potential savings of using CT to avoid unnecessary aortography. MATERIALS AND METHODS: The institutional review board approved the parallel imaging-CT immediately followed by aortography-of patients presenting with blunt chest trauma between August 1997 and August 1998. To screen patients for potential aortic injuries, we performed parallel imaging on 142 patients, and these patients comprised our patient population. CT examinations of the patients were reviewed for signs of injury by radiologists who were unaware of each other's interpretations and the aortographic results. Findings of CT examinations were classified as negative, positive, or inconclusive for injury. Aortography was performed immediately after CT. The technical and professional fees for both transcatheter aortography and helical CT were also compared. RESULTS: Our combined kappa value for all CT interpretations was 0.714. The aortographic sensitivity and negative predictive value were both 100%. Likewise, the sensitivity and negative predictive value of CT were 100%. The total costs of performing aortography were estimated at approximately $402,900, whereas those for performing helical CT were estimated at $202,800. CONCLUSION: Helical CT has a sensitivity and negative predictive value equivalent to that of aortography. Using CT to eliminate the possibility of mediastinal hematoma and to evaluate the cause of an abnormal aortic contour in a trauma patient allows us to use aortography more selectively. Avoiding the performance of unnecessary aortography will expedite patient care and reduce costs. We report the results of our experience with CT and how our center successfully made this transition in the initial examination of patients with serious thoracic trauma.

Coordinated righting behaviour in locusts.

A locust placed upside down on a flat surface uses a predictable sequence of leg movements to right itself. To analyse this behaviour, we made use of a naturally occurring state of quiescence (thanatosis) to position locusts in a standardised upside-down position from which they spontaneously right themselves. Locusts grasped around the pronotum enter a state of thanatosis during which the limbs can be manipulated into particular postures, where they remain, and the animal can be placed upside down on the ground. When released, thanatosis lasts 4-456 s (mean 73 s) before the animal suddenly becomes active again and rights itself within a further 600 ms. Thanatosis is characterised by very low levels of leg motor activity. During righting, one hind leg provides most of the downward force against the ground that rolls the body around a longitudinal axis towards the other side. The driving force is produced by femoral levation (relative to the body) at the trochanter and by tibial extension. As the animal rolls over, the hind leg on the other side is also levated at the trochanter, so that it does not obstruct the movement. The forelegs and middle legs are not required for successful righting but they can help initially to tip the locust to one side, and at the end of the movement they help stop the roll as the animal turns upright. Individual locusts have a preferred righting direction but can, nevertheless, roll to either side. Locusts falling upside down through the air use both passive and active mechanisms to right themselves before they land. Without active movements, falling locusts tend to rotate into an upright position, but most locusts extend their hind leg tibiae and/or spread their wings, which increases the success of mid-air righting from 28 to 49 % when falling from 30 cm. The rapid and reliable righting behaviour of locusts reduces the time spent in a vulnerable upside-down position. Their narrow body geometry, large hind legs, which can generate substantial dorsally directed force, and the particular patterns of coordinated movements of the legs on both sides of the body are the key features that permit locusts to right themselves effectively. The reliability of autonomous multi-legged robots may be enhanced by incorporating these features into their design.

Parallel somatotopic maps of gustatory and mechanosensory neurons in the central nervous system of an insect.

Relatively little is still known about the sense of taste, or contact chemoreception, compared with other sensory modalities, despite its importance to many aspects of animal behaviour. The central projections of the sensory neurons from bimodal contact chemoreceptors (basiconic sensilla) were compared with those from mechanosensory tactile hairs located on similar regions of the middle leg of the locust. Basiconic sensilla are multiply innervated, containing one mechanosensory and several chemosensory neurons, whereas tactile hairs are innervated by a single mechanosensory neuron. We show that the sensory neurons from tactile hairs form a complete 3-dimensional somatotopic map in the mesothoracic ganglion. Sensory neurons from hairs located on the coxa projected to a region near the midline of the ganglion with neurons from hairs located on progressively more distal parts of the leg arborizing in successively more lateral regions of neuropil. All the neurons from basiconic sensilla, both mechanosensory and chemosensory, also projected in a similar, strictly somatotopic, manner, and the arbors from these neurons overlapped considerably with those from tactile hairs on equivalent parts of the leg to form a continuous region. Thus, the position of a receptor on the leg is preserved in the central nervous system not only for the mechanosensory neurons from both tactile hairs and basiconic sensilla but also for chemosensory neurons. We could observe no anatomical features or small differences in projection region between sensory neurons from individual basiconic sensilla consistent with differences in modality.

Contralateral coordination and retargeting of limb movements during scratching in the locust

Locusts, Schistocerca gregaria, in common with many limbed vertebrates, can make directed scratching movements in response to tactile stimulation. For instance, stimulation of different sites on a wing elicits different movements that are accurately targeted so that the hindleg tarsus passes across the stimulus site. I have analysed these limb movements to define the ability of a locust to target stimulus sites correctly under a range of experimental conditions. In particular, I describe aspects of the behaviour that reveal possible neuronal pathways underlying the responses. These neuronal pathways will be the subject of further physiological analyses. Limb targeting during scratching is continuously graded in form; different patterns of movement are not separated by sharp transitions. The computation of limb trajectory takes into account the starting posture of the hindleg, so that different trajectories can be used to reach a common stimulus site from different starting postures. Moreover, the trajectories of the two hindlegs moving simultaneously from different starting postures in response to a single stimulus can be different, so that their tarsi converge onto the common stimulus site. Different trajectories can be used to reach a common stimulus site from the same start posture. Targeting information from a forewing is passed not only down the nerve cord to the ipsilateral hindleg but also across the nerve cord, so that the contralateral hindleg can also make directed movements. This contralateral transmission does not rely on peripheral sensory feedback. When the stimulus site moves during a rhythmical scratch, the targeting of subsequent cycles reflects this change. Both ipsilateral and contralateral hindlegs can retarget their movements. The trajectory of a single cycle of scratching directed towards a particular stimulus site can be modified after it has begun, so that the tarsus is redirected towards a new stimulus site.

Hindleg targeting during scratching in the locust

Intact locusts (Schistocerca gregaria) respond to tactile stimulation of their folded wings with rhythmic scratching movements of the ipsilateral hindleg that are directed towards the site of stimulation. For example, sites near the base of a wing elicit anteriorly directed scratches, whereas sites near the distal end of a wing elicit posteriorly directed scratches. Locusts also scratch in response to tactile stimulation of a wing that is held outstretched in a posture similar to that normally adopted during flight, but they fail to alter their leg targeting to compensate for this changed position of the stimulus site. Instead, they scratch at an empty point in space near the abdomen, where the stimulus site would have been if the wing was folded in the resting posture. This inappropriate scratching does not result from mechanical constraints on the hindleg's movement, from stimulation of abdominal sensory receptors, or from an absence of sensory information from the outstretched wing. It also persists when the metathoracic ganglion that controls movements of the hindlegs is isolated from the remainder of the central nervous system (CNS). Targeted scratching of sites on the wings of locusts therefore appears to be fixed relative to body coordinates and does not take into account alterations of the target wing's position.

Octopamine modulates the responses and presynaptic inhibition of proprioceptive sensory neurones in the locust Schistocerca gregaria

A multineuronal proprioceptor, the femoral chordotonal organ (feCO), monitors the position and movements of the tibia of an insect leg. Superfusing the locust metathoracic feCO with the neuromodulator octopamine, or the octopamine agonist synephrine, affects the position (tonic) component of the organ's response, but not the movement (phasic) component. Both octopamine and synephrine act with the same threshold (10(-6) mol l-1). Individual sensory neurones that respond tonically at flexed tibial angles show increased tonic spike activity following application of octopamine, but those that respond at extended angles do not. Tonic spiking of phaso-tonic flexion-sensitive neurones is enhanced but their phasic spiking is unaffected. Bath application of octopamine to the feCO increases the tonic component of presynaptic inhibition recorded in the sensory terminals, but not the phasic component. This inhibition should at least partially counteract the increased sensory spiking and reduce its effect on postsynaptic targets such as motor neurones. Furthermore, some phasic sensory neurones whose spiking is not affected by octopamine nevertheless show enhanced tonic synaptic inputs. The chordotonal organ is not known to be under direct efferent control, but its output is modified by octopamine acting on its sensory neurones to alter their responsiveness to mechanical stimuli and by presynaptic inhibition acting on their central branches. The effects of this neuromodulator acting peripherally on sensory neurones are therefore further complicated by indirect interactions between the sensory neurones within the central nervous system. Increases of sensory neurone spiking caused by neuromodulators may not necessarily lead to parallel increases in the responses of postsynaptic target neurones.

An elaborate tension receptor system highlights sensory complexity in the hind leg of the locust

The tibia of each leg of the locust is moved by two antagonistic muscles, the extensor and flexor tibiae. A variety of sense organs on and in each leg provide feedback about this joint's position and movement and about forces acting on the exoskeleton and muscles. One such organ is a muscle tension receptor found within the flexor tibiae muscle of the mesothoracic leg. We now show that an apparently homologous multipolar receptor is present in the hind leg, but that here it is associated with a specialised flexor muscle, the accessory flexor. This muscle comprises 13 fibres, innervated by five of the thirteen motor neurones that innervate the main flexor muscle and, since these are slow motor units, the response properties of the receptor are constrained. The multipolar receptor attaches to the muscle fibres near their proximal insertion onto the femoral cuticle. It generally has four primary dendrites, which do not branch extensively within the muscle. We show that the receptor responds strongly to active, isometric contractions but only poorly to imposed changes of accessory flexor muscle length (i.e. passive changes in tibial position). It does not respond to tension generated by the main flexor muscle or by the extensor muscle. The tension receptor causes short-latency (0.9­1.8 ms) excitatory inputs onto the three common inhibitory motor neurones and longer-latency (3.7­8.1 ms) inhibitory inputs onto the slow extensor tibiae motor neurone. In quiescent animals, it causes excitatory inputs onto flexor tibiae motor neurones (2.2­3.8 ms) but, in more active animals, its inputs onto these neurones are often inhibitory, with delays of 6­10 ms. The slow nature of the accessory flexor muscle and the pattern of central connections of the receptor suggest that together they are involved in the control of slow movements or posture, potentially acting through a servomechanism.

A presynaptic gain control mechanism among sensory neurons of a locust leg proprioceptor.

The chordotonal organ at the femorotibial joint of a locust hind leg monitors extension and flexion movements of the tibia. During evoked or imposed movements of this joint the central terminals of afferent neurons from the chordotonal organ receive depolarizing, inhibitory synaptic inputs. The afferent spikes are therefore superimposed on these depolarizing IPSPs, which are generated indirectly by other afferents from the same organ that respond to the same movement. Each afferent spikes preferentially to particular features of a joint movement, and its synaptic input is typically greatest at the joint position or during the movement that generates its best response. Afferents that respond to only one direction of movement receive synaptic inputs either during movements in both directions, or only during movements in their preferred direction. Phasic velocity-sensitive afferents receive either phasic inputs during movements, or tonic inputs at new sustained joint positions, or both. The spikes of tonic position-sensitive afferents are superimposed on synaptic inputs that are dependent on joint position. The synaptic inputs sum but do not themselves evoke antidromic spikes in the afferent terminals. They reduce the amplitude of orthodromic afferent spikes by 12-28%, and this is accompanied by a reduction of up to 50% in the amplitude of monosynaptic EPSPs evoked by an afferent in postsynaptic leg motor neurons. These interactions suggest that a local gain control mechanism operates between the afferents of this proprioceptor. Thus, the effectiveness of the output synapses of an individual afferent is regulated by the network action of other chordotonal afferents that respond to the same movement.

A simple computer-controlled analogue ramp generator for producing multiple ramp-and-hold stimuli.

This report describes an inexpensive ramp generator which produces multiple ramp-and-hold stimuli ("staircase-type" wave forms). The output voltage is analogue and is, therefore, free of stepping artifacts characteristic of digital function generators. When coupled with a standard power amplifier and mechanical vibrator, this system is particularly suitable for stimulation of mechanoreceptive sense organs. Connection to the serial port of an IBM personal computer, or the user port of a BBC computer allows complex ramp-and-hold sequences to be developed and repeated. The number, duration and sign of ramps, and the duration of intervening hold periods can be set using the computer. This system has been used successfully to characterise phasic and tonic neurones in the locust metathoracic femoral chordotonal organ (a leg position and movement detector).

Inpatient treatment of prolapsing piles: cryosurgery versus Milligan-Morgan haemorrhoidectomy.

A comparative retrospective study, based on clinical assessment and questionnaire analysis, of 97 patients treated by cryosurgical haemorrhoidectomy and 99 patients treated by Milligan-Morgan haemorrhoidectomy, at 4-year average follow-up, has shown that 70 per cent of patients in each group derived complete and lasting relief from their symptoms. Two patients in each group required further treatment. There was no significant difference between the numbers who remembered severe, moderate or mild pain, or in its duration, although fewer cryosurgical patients required opiates. Postoperative discharge ceased in 70 per cent of patients within 2 weeks. When skin tags remained, they were usually inconsequential. Anal stenosis following cryohaemorrhoidectomy did not occur, and has not been reported. Cryohaemorrhoidectomy gave results equal to Milligan-Morgan haemorrhoidectomy in patients with prolapsing piles, with fewer complications, and has the economic advantages of less time in hospital (P less than 0.01) and less time off work (P less than 0.01).

Chemotherapy following palliative resection of gastric cancer.

Twenty-five patients with residual tumour after resection of a primary gastric cancer were randomized to receive either 5-Fluorouracil or BCNU postoperatively or kept under close observation. Some patients receiving chemotherapy may have benefited by a delay in progression of their disease but this was short lived and subsequently all but one patient has died within a 4-year period of follow-up. There does not seem to be any advantage in treating patients who have residual gastric cancer with 5-FU and BCNU therapy.

Phase II study of chlorozotocin in the treatment of advanced colorectal cancer.

In 39 patients with advanced colorectal cancer and no previous chemotherapy, treatment with chlorozotocin was associated with a 5% objective response rate and a median survival of 19 weeks. All of the responses occurred in patients with rectal tumors. Mild gastrointestinal symptoms affected 64% of the patients after treatment, but bone marrow suppression was not evident. Chlorozotocin is not effective against colorectal cancer when used as a single agent given as an iv bolus at doses of 120 mg/m2 (30 patients) and 150 mg/m2 (nine patients). However, further studies using a higher dose might be worthwhile.

Several standard elective operations for duodenal ulcer: ten to 16 year clinical results.

A survey was undertaken of 558 men with duodenal ulcer who had been treated ten to 16 years previously by truncal vagotomy and drainage, truncal vagotomy and antrectomy and subtotal gastrectomy. Of the 558, 65 had died and 111, presumed living, could not be traced, leaving 382 available for assessment. Between 75 and 85% of the traced patients were considered to have an excellent or very good result, which is a slight improvement on the previously published results in this same group of patients at five to eight years follow-up. Some of the side effects of operation had diminished slightly in frequency and there had been no significant increase in the incidence of recurrent ulceration since the previous survey. Anemia was an uncommon finding. As between the various forms of operation, truncal vagotomy and antrectomy and subtotal gastrectomy demonstrated significantly better protection against proven recurrent ulcer than did truncal vagotomy and pyloroplasty (p less than 0.05). Compared with truncal vagotomy and gastroenterostomy, however, the results of both resection operations, though better, did not achieve statistical significance at p - 0.5 level (p less than 0.1). In regard to Visick gradings the resection procedures had better scores, but the differences were not significant at the p - 0.05 level, except for vagotomy and antractomy as compared with vagotomy and pyloroplasty. But it is stressed that in formulating a policy of surgical therapy for duodenal ulcer the greater inherent immediate risks of resection operations need to be borne in mind.

Microprocessor assisted real-time harmonic analysis by minicomputer.

A real-time signal averaging and harmonic analysis technique for low audio frequency waveforms is described that, although based on based on earlier software emulations of lock-in detection instruments, eliminates problems inherent in the earlier systems. Parallel processing is employed between a data acquisition minicomputer (HP-2116B) and a microcomputer (Z-80) to (1) replace an earlier chopper-type lock-in algorithm with a coherent Fourier transform, (2) digitally produce a pure (0.01% THD) modulation sine wave, (3) simplify system tune-up, and (4) produce a high-quality, flicker-free, real-time display of the averaged waveform and its harmonic content.

Five- to eight-year results of truncal vagotomy and pyloroplasty for duodenal ulcer.

From January 1963 to December 1965 inclusive 192 men with duodenal ulcer were treated by elective truncal vagotomy and pyloroplasty with one death. Ten subsequent deaths were due to causes unrelated to the ulcer or operation, and 17 patients became untraceable. The remaining 164 patients have been followed up for five to eight years. The late results have been compared with those obtained in a previous study of patients five to eight years after truncal vagotomy and gastroenterostomy, truncal vagotomy and antrectomy, and subtotal gastrectomy respectively for duodenal ulcer.Of the various postgastric operation syndromes early dumping, late dumping, bilious vomiting, and diarrhoea were all less frequent, but not significantly so, after vagotomy and pyloroplasty than after vagotomy and gastroenterostomy.Recurrent ulceration was commoner after vagotomy and pyloroplasty than after all the other operations, the incidence of proved and suspected recurrent ulcers being respectively 6.7 and 7.3% after vagotomy and pyloroplasty, but only 2.5 and 5.9% after vagotomy and gastroenterostomy, 0 and 5.2% after vagotomy and antrectomy, and 0.9 and 3.7% after subtotal gastrectomy. The differences between vagotomy and pyloroplasty and vagotomy and antrectomy or subtotal gastrectomy are statistically significant, but those between vagotomy and pyloroplasty and vagotomy and gastroenterostomy are not.Overall assessment (Visick grading) of the outcome gave poorer results after vagotomy and pyloroplasty than after any other operation, with 14% of category IV cases after vagotomy and pyloroplasty, 11% after vagotomy and gastroenterostomy, 8% after vagotomy and antrectomy, and 6% after subtotal gastrectomy-differences that are significant between vagotomy and pyloroplasty and vagotomy and antrectomy or subtotal gastrectomy but not between vagotomy and pyloroplasty and vagotomy and gastroenterostomy.In the light of these findings it is suggested that truncal vagotomy and pyloroplasty has not lived up to expectations and its place as the currently most popular procedure in the elective surgical treatment of duodenal ulcer should be reconsidered.