Stakeholder Assessment of Evidence-Based Guideline Dissemination and Implementation in a Dental Group Practice.

OBJECTIVE: This evaluation captures the perspectives of multiple stakeholders within a salaried dental care delivery organization (dentists, dental assistants, dental hygienists, and dental management) on the implementation of a pit-and-fissure sealant guideline in the Kaiser Permanente Dental Program. Also assessed is the role of formal processes and structures in providing a framework for guideline implementation. METHODS: We collected qualitative data through field observations, stakeholder interviews (n = 6), and focus groups (30 participants in 5 focus groups). Field observation notes captured summaries of conversations and other activities. Interviews and focus groups were recorded and transcribed. We analyzed transcripts and field notes using a template analysis with NVivo 12 software to identify themes related to the existing implementation process of clinical guidelines and stakeholder perspectives on the strengths and weaknesses of this process. RESULTS: Stakeholders perceived 2 main barriers for achieving implementation of the pit-and-fissure sealant guideline: 1) shortcomings in the implementation infrastructure resulting in lack of clarity about the roles and responsibilities in the guideline implementation process and lack of effective mechanisms to disseminate guideline content and 2) resource constraints, such as limited human, space, and material resources. Perceived opportunities for the dissemination and implementation of guidelines included recognition of the importance of guidelines in dental practice and well-functioning workflows within dental specialties. CONCLUSION: Our research points to the importance of developing and maintaining an infrastructure to ensure standardized, predictable mechanisms for implementation of guidelines and thereby promoting practice change. While addressing resource constraints may not be possible in all circumstances, an important step for improving guideline implementation-wherever feasible-would be the development of a robust implementation infrastructure that captures and delineates roles and responsibilities of different clinical actors in the guideline implementation process. KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by health care leadership and administrators to understand possible reasons for a lack of guideline implementation and provide suggestions for establishing sustainable infrastructure to promote the adoption of clinical guidelines in salaried dental clinics.

Towards a Role for Clinical Pathology Diagnostics for Childhood Maltreatment.

Recent reports from the Center for Disease Control and Kaiser Permanente demonstrate that early life adverse experience leads to morbidity and mortality in adulthood. To date there are no objective tests that help care-givers or local child protective services make informed decisions for children with a history of abuse, neglect or trauma. This is the first report from a new group of trans-disciplinary investigators describing a new approach to identify the biological impact of childhood maltreatment using clinical pathology testing. Such new quantitative measurements will be useful to identify children at risk for poor mental and physical health outcomes and to follow response to interventions.

Spt5 and spt6 are associated with active transcription and have characteristics of general elongation factors in D. melanogaster.

The Spt4, Spt5, and Spt6 proteins are conserved throughout eukaryotes and are believed to play critical and related roles in transcription. They have a positive role in transcription elongation in Saccharomyces cerevisiae and in the activation of transcription by the HIV Tat protein in human cells. In contrast, a complex of Spt4 and Spt5 is required in vitro for the inhibition of RNA polymerase II (Pol II) elongation by the drug DRB, suggesting also a negative role in vivo. To learn more about the function of the Spt4/Spt5 complex and Spt6 in vivo, we have identified Drosophila homologs of Spt5 and Spt6 and characterized their localization on Drosophila polytene chromosomes. We find that Spt5 and Spt6 localize extensively with the phosphorylated, actively elongating form of Pol II, to transcriptionally active sites during salivary gland development and upon heat shock. Furthermore, Spt5 and Spt6 do not colocalize widely with the unphosphorylated, nonelongating form of Pol II. These results strongly suggest that Spt5 and Spt6 play closely related roles associated with active transcription in vivo.

Post-transcriptional control of cyclooxygenase-2 gene expression. The role of the 3'-untranslated region.

The cyclooxygenase (COX)-2 enzyme is responsible for increased prostaglandin formation in inflammatory states and is the major target of nonsteroidal anti-inflammatory drugs. Normally COX-2 expression is tightly regulated, however, constitutive overexpression plays a key role in colon carcinogenesis. To understand the mechanisms controlling COX-2 expression, we examined the ability of the 3'-untranslated region of the COX-2 mRNA to regulate post-transcriptional events. When fused to a reporter gene, the 3'-untranslated region mediated rapid mRNA decay (t(1/2) = 30 min), which was comparable to endogenous COX-2 mRNA turnover in serum-induced fibroblasts treated with actinomycin D or dexamethasone. Deletion analysis demonstrated that a conserved 116-nucleotide AU-rich sequence element (ARE) mediated mRNA degradation. In transiently transfected cells, this region inhibited protein synthesis approximately 3-fold. However, this inhibition did not occur through changes in mRNA stability since mRNA half-life and steady-state mRNA levels were unchanged. RNA mobility shift assays demonstrated a complex of cytoplasmic proteins that bound specifically to the ARE, and UV cross-linking studies identified proteins ranging from 90 to 35 kDa. Fractionation of the cytosol showed differential association of ARE-binding proteins to polysomes and S130 fractions. We propose that these factors influence expression at a post-transcriptional step and, if dysregulated, may increase COX-2 protein as detected in colon cancer.

How ageing and social factors affect memory.

OBJECTIVES: To explore the relationships between lifestyle and memory, and determine whether social factors influence memory. METHODS: the relationship between memory and lifestyle was examined in 497 adults aged 25-80 years, using the Mectamemory in Adulthood questionnaire. We asked about sports activity and perceived activity, participation in voluntary organizations and social contacts. RESULTS: Activity and frequent contact with friends and family were related to higher memory capacity scores. Those with higher capacity scores were also younger, had better health and a stronger internal locus of control. In contrast, people with higher anxiety scores had more symptoms and less education, and were more externally oriented. CONCLUSIONS: people who consider themselves socially and physically active also consider their memory capacity to be good and are less anxious about their memory than less socially and physically active people. Perceived memory change appears to be predominantly influenced by ageing, whereas memory capacity and memory anxiety are more influenced by social factors.

The design and effectiveness of therapeutic community research in Europe: an overview.

An overview of the state of the art of research on the treatment services of the therapeutic community for drug addicts in Europe is presented. This research tradition has largely been fragmented and local in its implementation. There has been a scientific gap concerning evaluation research and the treatment services offered by the therapeutic community. The American research antecedents to the European tradition are reviewed. The essential European groups, research designs and results are presented for each country with something greater than an ad hoc study experience. The strengths and weaknesses of the research designs, results and organizations are critically assessed. Recommendations for future research are presented and referenced to specific recommendations for therapeutic community research coming out of an American National Institute on Drug Abuse Technical Review. Among the conclusions of the overview is the need for more qualitative phenomenological research to complement the existing quantitative approach.

The legal importation of prescription drugs into the United States from Mexico: a study of Customs declaration forms.

The nature and magnitude of the problem of the diversion of prescription drugs from legal to illegal markets have been identified as a high priority by the federal government. This study was based on a random sample (2,005) of declaration forms of persons declaring Mexican prescription drugs at the US Customs office in Laredo, Texas. Of the 75 different types of drugs, the most frequently declared drugs were Valium (71%), Rohypnol (46%), and Tafil (25%), drugs highly associated with nonmedicinal use among United States teenagers and young adults. These data reinforce a documented need for more transnational cooperative efforts between the United States and Mexico.

L-Methadone and D,L-methadone in methadone maintenance treatment: a comparison of therapeutic effectiveness and plasma concentrations.

The clinical effectiveness of l-methadone maintenance treatment (LMMT) carried out using d,l-methadone or l-methadone have been compared with ambulatory heroin-dependent subjects. A total of 40 heroin-dependent subjects, previously maintained on l-methadone in Frankfurt am Main, were divided into two groups under randomised double-blind conditions and received either an equivalent dose of l-methadone as d,l-methadone or remained on the previous l-methadone treatment. Requests for a change in the dose of d,l-methadone and l-methadone were recorded, urine samples for determination of illicit drug use were collected and the individual level of opiate craving was determined over a 22-day observation period. There was no significant difference between the two groups in the number requests for a dose change (dose increase <10%). However, there was a significant increase in heroin use in the group which continued to receive l-methadone. Although there was less variability in opiate craving in the group receiving d,l-methadone, the mean intensity of opiate craving did not differ between the two groups. The mean l-methadone dose:l-methadone plasma concentration ratio, an index of the bioavailability of l-methadone in individual subjects, showed no significant change when the treatment was changed to d,l-methadone. The mean d-methadone:l-methadone plasma concentration ratio was 1.17. There was no significant difference between these ratios for day 15 and day 22. The mean l-methadone:EDDP plasma concentration ratio in the l-methadone group was 22.2 and the d,l-methadone:EDDP plasma concentration ratio was 18.4 . The plasma EDDP concentration in the d,l-methadone group increased 3-fold after starting treatment with d, l-methadone. These findings suggest that d,l-methadone can be used in methadone maintenance treatment of heroin-dependent subjects but that further studies are required to evaluate pharmacokinetic interactions between methadone enantiomers.

A comparison of alcohol, drugs, and aggressive crime among Mexican-American, black, and white male arrestees in Texas.

Few comparative studies exist examining the relationship between substance abuse and aggressive behavior under different social conditions. We studied the relationship between aggressive crime and substance abuse among Mexican-American, black and white male arrestees in Dallas, Houston, and San Antonio, Texas using existing 1992 Drug Use Forecasting (DUF) data. The aim of the analysis was to predict the outcome of aggressive crime from drug and alcohol-related and ethnic group variables within the total male sample (n = 2,364). Results indicated that ethnicity was significantly related to aggressive crime. Mexican-American arrestees were more likely to be arrested for aggressive crimes than either blacks or whites. Drug and alcohol use effects were found across all ethnic groups. In general, the subgroup which drank frequently and tested positive for drug use was less likely to be charged with aggressive crimes than the other subgroups. The psychopharmacological influence of alcohol as a disinhibitor and drugs as a inhibitor provides one explantation of the results. Specific ethnic subcultural and ecological influences also affect the outcome. Our study strongly indicates the heterogeneous character of the drug using population in relation to aggression. The variability between subculturally defined subgroups requires detained ethnographic field studies in the future to describe the contexts of substance use and aggressive behavior.

Risk contexts and risk behaviors in the Euregion Maas-Rhein: the Boule de Neige intervention for AIDS prevention among drug users.

Using targeted sampling, self-reported data of 1,767 drug users in the Euregion Maas-Rhein were collected over 3 years. Forty-two percent of the injection drug users shared syringes with sexual partners and 47.8% with friends. Eighty-one percent of the total sample had sexual contact in the last 6 months, half of whom with one person and half with two or more. Significant predictors of high-risk drug use were injecting in the presence of others, injection onset before the age of 20, female gender, and not living in The Netherlands. Participation in needle exchange or methadone programs and sufficient knowledge of risk factors was not significantly related to a reduction of high-risk drug use behavior. High-risk sexual behavior was found to be related to male gender, under the age of 30 and to multiple sexual partners. We conclude that in a social context where needle exchange, methadone programs, and sufficient knowledge of risk factors among the drug user population exist, AIDS prevention can be improved through behavioral skills training and developing specific interventions that target the peer group environments, rituals, partner relationships, and lifestyles of drug users.

PIP: A 3-year (1992-94) prospective study of 1767 drug users from the Euregion Maas-Rhein evaluated a peer counseling intervention for reducing risk behaviors associated with HIV transmission. The HIV prevalence among drug users in this diverse Dutch, German, and Belgian area ranges from 10% to 30%. Duties of the paid peer counselors included promotion of HIV risk reduction in drug use and sexual behavior; administration of questionnaires; distribution of educational materials, condoms, and clean needles; identification of hidden subgroups in the target population; and the development of prevention materials. 50% of those reached by peer counselors had no prior contact with drug abuse services. Although drug users claimed syringes and condoms were readily available, high-risk drug and sexual behaviors were widespread. 52% were injecting drugs and 24.4% had traded drugs for sex. Condoms were used by 24.8% during sexual contacts with a main partner and by 73.5% during sex with casual partners. 47.8% of injecting drug users had shared their syringes with friends. Condom use was significantly higher among drug users residing in South Limburg, women, those over 30 years of age, and those with multiple sex partners. These findings suggest that existing HIV risk-reduction interventions such as methadone treatment and needle exchange may not be sufficient. More emphasis must be placed on personal skills training (e.g., assertiveness training) and peer-driven, lifestyle-oriented processes.

Naturalistic assessments in psychiatry.

Research in psychiatry could speeden its progress by taking the manifest heterogenity and variability of symptom expression within diagnostic groups more fully into account. Since Kraepelin symptom variation has been recognized to have both biological and environmental roots. If investigated systematically, such variations in illness experience will yield new subtypes that will provide greater insight into the onset, course and vulnerability of mental disorders. Studies ranging from population surveys to the laboratory have demonstrated that psychopathology is not randomly distributed in a population, nor is it constantly present in the lives of individuals. At both the population and the person levels, psychopathology varies with time and place. At the population level, illness processes localize in risk groups, who often reside in specific neighbourhoods or social settings. The individual experience of psychopathology also fluctuates with time, place and culture. This variability requires methods for case detection and treatment planning that take this into account.

The social network characteristics of fibromyalgia patients compared with healthy controls.

OBJECTIVE: To assess structural social network characteristics and perceived loneliness in fibromyalgia syndrome (FMS) patients and healthy controls. METHODS: A cross-sectional, retrospective, case-control design was employed using a structured interview and a self-report questionnaire. We studied 25 female FMS patients and 25 matched healthy female controls. RESULTS: FMS patients had statistically significantly (P < 0.05) more intimate friends (mean 4.5) and more health care providers (mean 1.5) than did controls (2.3 and 0.0, respectively). The FMS patients more often initiated the contact with family members (mean 2.1) than did controls (mean 0.8). FMS patients did not perceive themselves as lonelier than controls perceived themselves. While there was a significant negative correlation between loneliness and social network variables among the controls, this relationship was not significant among the FMS patients. Among the patients, there was a strong correlation between the total social network size and the number of intimate friends, whereas in controls, the mean number of acquaintances was strongly correlated with the total network size. CONCLUSION: Compared to healthy controls, the social networks of FMS patients presented more linkages with intimate friends, family members, and health care providers. The lack of correlation between loneliness and social network variables for FMS patients is not what might be expected from social support theory. The assessment of structural social network characteristics along with social support variables may add to our understanding of the social functioning of FMS patients.

Retinal degeneration characterizes a spinocerebellar ataxia mapping to chromosome 3p.

A heterogeneous group of neurological disorders known as the spinocerebellar ataxias (SCA) are characterized by degeneration of the cerebellum, spinal cord and brainstem. We describe linkage analysis in four unusual SCA families revealing a distinct disease locus on chromosome 3p14-21.1. The disease in these families is distinguished from other forms of SCA by concomitant retinal degeneration. Initial visual problems leading to blindness, disabling ataxia and anticipation are seen in all kindreds. The anticipation in these families suggests a dynamic mutation at this locus. Eventual molecular characterization of this disease may provide valuable insights into the processes of both neural and retinal degeneration.

Illegal drug use, alcohol and aggressive crime among Mexican-American and white male arrestees in San Antonio.

This research explores the relationship between use of certain drugs and aggressive crimes among Mexican-American and White male arrestees in San Antonio, Texas, for 1992. This is based on a Drug Use Forecasting (DUF) sample of 534 male arrestees administered a drug urine analysis test and questionnaire by the Department of Justice and the city of San Antonio. Using a four-way asymmetrical analysis, logit-models were tested to examine the relationships between the response variable, the types of crimes charged (nonaggressive versus aggressive) and a set of exploratory variables, ethnicity (White versus Hispanic), drug test results (positive versus negative), and alcohol use (infrequent versus frequent). The logit-analysis allows the specification of a subset of relevant models to be tested for their adequacy of fit. Findings indicate a complex but interpretable pattern between drug use, alcohol use patterns, and aggressive crimes. A surprising finding was that more aggressive crimes were committed by all men testing negative for drugs. Mexican-Americans with frequent alcohol use and testing positive for drugs were twice as likely to commit an aggressive crime (a crime associated with violence) than Whites in the same subgroup. The implication of these findings for prevention strategies aimed at alcohol and other drug users involved in violent behavior is discussed.

The prevention of stimulant misuse.

The term 'stimulant' refers to a class of drugs that increase psychophysiological arousal. From the viewpoint of prevention, it is more useful to look primarily at the social consequences and functions of stimulants. Every society has a documented use of stimulants. When planning interventions the dynamics of use must be placed in the foreground. Stimulant epidemics, like problematic stimulant users, have a natural tendency to burn themselves out. Different types of stimulants may differ in their origins, but their epidemiological consequences and use functions tend to be similar. Implications for prevention can be drawn from the characteristics of stimulant use epidemics. Users at risk for socially unacceptable patterns should be targeted for prevention efforts. Mass media campaigns that single out stimulants should be avoided. Much of the harm associated with stimulants is a consequence of life-styles characterized by polydrug use and unhealthy practices. Prevention should be timed to the appropriate period of the epidemic. Interventions useful at period 1 will not work at period 2. The recommendations of the WHO Advisory Group on the Adverse Effects of Cocaine and Coca provide a good model for primary, secondary and tertiary prevention for all forms of stimulant misuse. Stimulant prevention must be creative in finding ways of encouraging the movements of the drug to the periphery of users' lives.

The effects of orally active enkephalinase inhibitors on morphine withdrawal syndrome.

Considerable evidence has accumulated to suggest that intracerebroventricular administration of enkephalinase inhibitors, which do not penetrate the blood-brain barrier, significantly attenuates opioid withdrawal syndrome. Therefore, the aim of this study was to examine the effect of intraperitoneal (i.p.) administration of orally active enkephalinase inhibitors, acetorphan (2.5-20 mg kg-1) and SCH 34826 (15-120 mg kg-1). These drugs significantly decreased the severity of the naloxone precipitated withdrawal syndrome in morphine dependent rats and mice. It therefore appears that these orally active enkephalinase inhibitors are promising tools in studying modulation of opioid dependence phenomena.

Drug use contexts and HIV-consequences: the effect of drug policy on patterns of everyday drug use in Rotterdam and the Bronx.

Epidemiological data on HIV seroprevalence has been essential in assessing the (future) extent of the AIDS epidemic. By coupling these data with quantifiable variables related to injection drug use (frequency of injecting, number of needle sharing partners) specific 'risk behaviors' could be determined, accounting for the rapid spread of the virus in the injecting drug user (IDU) population. Yet, such data give little information on the social mechanisms and setting generating such risk behaviors. In order to understand the transmission of HIV among the IDU population one needs to study the micro settings and social context of drug use. This paper describes and explores certain patterns of drug use, sharing, and natural support systems found amongst IDUs in two very different cities, Rotterdam (The Netherlands) and the Bronx, New York City (USA). By specifying details of the micro-settings of everyday drug use in both locales, it is possible to identify certain common elements and consequences of personal and social behavior driven by drug use per se (e.g. drug preference), and to differentiate these from behaviors and consequences determined by drug policy and the social context in which drug use actually occurs. These policies and the social context they create can in turn be shown to relate to risks for HIV transmission, e.g. the increased likelihood of sharing injection equipment. A more careful ethnographic approach, taking advantage of natural experimental opportunities, comparisons and controls, may be utilized to examine drug-related behaviors in their social context and to better assess their relevance to public health--especially to AIDS.