Cardiopulmonary exercise testing and cardiopulmonary morbidity in patients undergoing major head and neck surgery.

Cardiopulmonary exercise testing (CPET) is used as a risk stratification tool for patients undergoing major surgery. In this study, we investigated the role of CPET in predicting day five cardiopulmonary morbidity in patients undergoing head and neck surgery. This observational cohort study included 230 adults. We recorded preoperative CPET variables and day five postoperative cardiopulmonary morbidity. Full data from 187 patients were analysed; 43 patients either had incomplete data sets or declined surgery/CPET. One hundred and nineteen patients (63.6%) developed cardiopulmonary morbidity at day five. Increased preoperative heart rate and duration of surgery were independently associated with day five cardiopulmonary morbidity. Those with such morbidity also had lower peak V̇O2 11.4 (IQR 8.4-18.0) vs 16.0 (IQR 14.0-19.7) ml.kg-1.min-1, P<0.0001 and V̇O2 at AT 10.6 (IQR 9.1-13.1) vs 11.5 (IQR 10.5-13.0) ml.kg-1.min-1, p=0.03. Logistic regression model containing peak V̇O2 and duration of surgery demonstrated that increased peak V̇O2 was associated with a reduction in the likelihood of cardiopulmonary complications OR 0.92 (95%CI 0.87 to 0.96), p=0.001. The area under the receiver operating characteristic curve for this model was 0.75(95%CI 0.68 to 0.82), p<0.0001, 64% sensitivity, 81% specificity. CPET can help to predict day five cardiopulmonary morbidity in the patients undergoing head and neck surgery. A model containing peak V̇O2 allowed identification of those with such complications.

Preoperative systemic inflammation and perioperative myocardial injury: prospective observational multicentre cohort study of patients undergoing non-cardiac surgery.

BACKGROUND: Systemic inflammation is pivotal in the pathogenesis of cardiovascular disease. As inflammation can directly cause cardiomyocyte injury, we hypothesised that established systemic inflammation, as reflected by elevated preoperative neutrophil-lymphocyte ratio (NLR) >4, predisposes patients to perioperative myocardial injury. METHODS: We prospectively recruited 1652 patients aged ≥45 yr who underwent non-cardiac surgery in two UK centres. Serum high sensitivity troponin T (hsTnT) concentrations were measured on the first three postoperative days. Clinicians and investigators were blinded to the troponin results. The primary outcome was perioperative myocardial injury, defined as hsTnT≥14 ng L-1 within 3 days after surgery. We assessed whether myocardial injury was associated with preoperative NLR>4, activated reactive oxygen species (ROS) generation in circulating monocytes, or both. Multivariable logistic regression analysis explored associations between age, sex, NLR, Revised Cardiac Risk Index, individual leukocyte subsets, and myocardial injury. Flow cytometric quantification of ROS was done in 21 patients. Data are presented as n (%) or odds ratio (OR) with 95% confidence intervals. RESULTS: Preoperative NLR>4 was present in 239/1652 (14.5%) patients. Myocardial injury occurred in 405/1652 (24.5%) patients and was more common in patients with preoperative NLR>4 [OR: 2.56 (1.92-3.41); P<0.0001]. Myocardial injury was independently associated with lower absolute preoperative lymphocyte count [OR 1.80 (1.50-2.17); P<0.0001] and higher absolute preoperative monocyte count [OR 1.93 (1.12-3.30); P=0.017]. Monocyte ROS generation correlated with NLR (r=0.47; P=0.03). CONCLUSIONS: Preoperative NLR>4 is associated with perioperative myocardial injury, independent of conventional risk factors. Systemic inflammation may contribute to the development of perioperative myocardial injury. CLINICAL TRIAL REGISTRATION: NCT01842568.

Natural human antibodies to pneumococcus have distinctive molecular characteristics and protect against pneumococcal disease.

The molecular and functional characteristics of natural antibody from the preimmune repertoire have not been explored in detail in man. We describe seven human IgM monoclonal antibodies selected on the basis of pneumococcal polysaccharide binding that share both molecular and functional characteristics with natural antibody, suggesting a common B cell lineage origin. Unlike class-switched antibodies, which are serotype-specific, the antibodies were polyreactive and bound all pneumococcal polysaccharide capsular serotypes tested. Some bound endogenous antigens, including blood group antigens and intermediate filament proteins. All the antibodies used unmutated heavy chain V (IGHV) that are expressed at an increased frequency in the elderly and in the preimmune repertoire. The CDR3 was characterized by long length (mean aa 18.4 (+/-4.2) and selective use of IGHD6 (P < 0.001) and IGHJ6 (P < 0.01) family genes. The clones expressing IGHV1-69 and IGHV 3-21 provided significant passive protection against invasive pneumococcal disease in vivo.

Endotoxin immunity and the development of the systemic inflammatory response syndrome in critically ill children.

BACKGROUND: The systemic inflammatory response syndrome (SIRS) may be triggered by endotoxin. Humans have antibodies directed against the core of endotoxin (endotoxin core antibodies, EndoCAb) that appear to be protective following surgery and in sepsis. We hypothesised that children with elevated antibodies to endotoxin core would be less likely to develop SIRS in their initial period on intensive care. Because of the existing literature we defined two sub-groups according to the primary reason for ICU admission: infection and non-infection. METHODS: We recruited 139 consecutive patients admitted to a paediatric intensive care unit (PICU) with more than one organ failure for longer than 12 h as part of another study. Patients were classified on admission to PICU as having an infectious or a non-infections diagnosis. The occurrence of SIRS within 48 h of admission was recorded along with detailed clinical and demographic data, EndoCAb concentration and the potential confounding variables C-reactive protein and mannose-binding lectin. RESULTS: In the 71 patients admitted without infection (primarily post-operative and head injured) IgG EndoCAb was significantly lower in patients who developed SIRS than those who did not (72 vs. 131 MU/ml), independent of potential confounding variables. In patients with infection there was no significant difference in IgG EndoCAb between children developing SIRS and those who did not (111 vs. 80 MU/ml). CONCLUSION: Head injured and post-operative patients admitted to PICU who develop early SIRS have significantly lower serum IgG EndoCAb levels than those who do not.

The Ohio Substance Abuse Monitoring Network: constructing and operating a statewide epidemiologic intelligence system.

Working with the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) and researchers at the University of Akron, Wright State University's Center for Interventions, Treatment, and Addictions Research developed the Ohio Substance Abuse Monitoring (OSAM) Network to provide a statewide summary of substance abuse trends. Ten key informants across the state collect qualitative and statistical data on substance abuse trends in their regions and prepare biannual reports. The OSAM network has a rapid response capability through which key informants can investigate special issues related to substance abuse identified by ODADAS and provide policymakers with timely, statewide reports. Within 12 months after operations began, the key informants produced reports on drug abuse trends and rapid response issues for the state. These reports prepared policymakers to respond more effectively to prevention and substance abuse treatment needs.

Drugs and prisoners: treatment needs on entering prison.

An interview study was conducted among a group of incoming prisoners in a county jail in Ohio during the summers of 1997 and 1998 to assess their current drug treatment needs. "Incoming prisoners" refers to individuals who were being transferred from this county jail to the state prison system. Marijuana and cocaine were the most commonly tried illegal drugs among the subjects as well as the drugs of choice during the month prior to imprisonment. The Diagnostic Interview Schedule, combined with questions employed in the Drug Use Forecasting (DUF) project, was used to construct the questionnaire for this study. Based on the criteria of DSM-IV diagnoses, 57.5% of those interviewed had exhibited drug dependency at some point in their lives, and 51% were currently dependent on some substance. Thus, more than half of the incoming prisoners were in need of treatment for use of at least one substance. Cocaine dependence was the greatest problem facing this group of inmates, with an especially notable problem among the older females. Younger males were more likely to have current marijuana dependence. The study found that individuals currently dependent on cocaine or opiates perceived that they had a need for drug treatment, while those currently dependent on marijuana did not share this perception.

Human immunodeficiency virus (HIV)-related risk-taking behaviors in women attending inner-city prenatal clinics in the mid-west.

OBJECTIVE: Federal guidelines recommend the provision of human immunodeficiency virus education to all attendees of prenatal clinics. The current study was conducted to assess risk-taking behaviors among urban women voluntarily pursuing prenatal care. DESIGN AND SETTING: African American women attending urban prenatal clinics in Cleveland, Ohio were subjected to an extensive interview before receiving an experimental AIDS education curriculum. The interview sought detailed information regarding demographics, lifetime and recent sexual activity, condom use, and lifetime and recent illicit drug use. RESULTS: A total of 1017 women were interviewed; of those women, approximately 73% were single. The majority had a monthly income of less than $500. A total of 66% had only one partner in the past year, and almost 90% had < or = 1 partner in the past 6 months. A total of 98% identified a main partner. Nearly all subjects were at least fairly certain that this partner did not use intravenous drugs, and 71% were at least fairly certain that he was monogamous. Only 19% used condoms most or all the time. Intravenous drug use among study subjects was very infrequent. CONCLUSION: These data indicate that inner-city Cleveland women seeking prenatal care are largely monogamous around the time of their gestation, and that a history of intravenous drug use is infrequent. They suggest that prenatal counseling in urban clinics will need to address women who largely are engaged in single-partner relationships at the time of the intervention.

Effectiveness of HIV/AIDS interventions on drug use and needle risk behaviors for out-of-treatment injection drug users.

Abstract-This study presents an evaluation of the effectiveness of the AIDS Community-Based Outreach/Intervention projects implemented as part of the National Institute on Drug Abuse (NIDA) Cooperative Agreement (CA), which began in 1990 and is currently ongoing. Participants in the CA were randomly assigned to one of two interventions: a NIDA/CA-developed standard intervention (SI); or the SI plus a site-specific enhanced intervention (EI). Analyses of drug use and needle-related risk behaviors were conducted among injection drug users (IDUs) in eight participating cities where follow-up rates of at least 60% were obtained (N=3,743). Results indicated that IDUs significantly reduced their needle-related risk behaviors following delivery of the interventions and that a substantial portion entered substance abuse treatment. However, there was relatively little to support the effectiveness of more expensive and involved enhanced interventions. A number of factors associated with increasing or maintaining high risk behaviors, including an HIV negative serostatus and a greater perceived chance of acquiring AIDS, were also observed. Continued outreach to drug injectors is recommended, as well as the development of new and creative interventions targeting individuals who are HIV negative and those who are aware of their high risk status but have not changed their behaviors in response to risk-reduction interventions.

Afrocentric treatment in residential substance abuse care. The Iwo San.

Alcohol and other drug treatment programs continue to report relatively low success rates among African-American participants. We propose that there is a need to consider treatment approaches that are more culturally competent. An Afrocentric paradigm is suggested and instituted as the central theme of a residential drug treatment program. Elements of an Afrocentric orientation and how these principles are used to guide the development of a treatment philosophy are discussed.

Assessing substance abuse treatment needs among the homeless: a telephone-based interactive voice response system.

OBJECTIVES: We report on a pilot project that used a telephone-based interactive voice response system accessed by cellular phones at diverse sites, to interview homeless persons on their need for alcohol and other drug treatment. METHODS: Using this technique we surveyed 207 homeless adults at eight shelters in Cleveland, Ohio. RESULTS: The cellular approach was comparable to human-administered interviews in reliability and validity and yielded higher self-reported levels of drug use. CONCLUSIONS: Cellular telephones and interactive voice response interviewing systems can be useful tools in assessing for the health-service needs of difficult-to-reach populations.

Computer services for patients. Description of systems and summary of findings.

This article (1) describes a number of computer services provided to patients' homes, (2) summarizes four evaluation studies reported in this supplement, and (3) suggests direction for future research. The studies reviewed in this article suggest that computer services have little impact on patients' health status but a significant impact on use of services. Some computer services (eg, reminders) increase client visits and other services (eg, voice bulletin board) reduce clinic visits. The article suggests that a paradigm for conducting research on impact of home computer services on care of patients is missing and should be developed.

A randomized trial of a telecommunications network for pregnant women who use cocaine.

OBJECTIVES: The authors describe computer services designed to make patients better informed and more motivated to participate in treatment. Patients use these services through their touch-tone telephone; access to a home computer or a modem is not needed. METHODS: The authors tested the impact of these computer services on the management of 179 pregnant women who had used cocaine during pregnancy or 1 month before pregnancy (as reported by the woman). Patients were randomly assigned to control and experimental groups; only the experimental group had access to the computer services. Patients were enrolled during the prenatal period and followed for 6 months after the birth of a live child. Self-reported data on the subjects' participation in drug treatment programs, health status (using the SF-36), and addiction severity (using the addiction severity index) were collected. The computer collected data on the frequency of the use of the service. The dependent variables were participation in formal treatment during the course of the project, and drug and alcohol use at exit interview. Multiple and logistic regressions were used to identify the effects of the intervention after controlling for demographic and baseline variables. RESULTS: Data showed that poor, pregnant, undereducated clients who use drugs and lived in multiple residences could use the services; about one-third of clients used the services more than three times a week. Access to the service did not lead to significant change in patients' health status, drug use, or utilization of services. Use of the services did lead to significant changes in participation in drug treatment: subjects who used the service more than three times a week were 1.5 times more likely to participate in formal drug treatment than subjects who used the service less often. Participation in formal drug treatment, however, was not effective in reducing the drug or the alcohol use. CONCLUSIONS: Almost all patients used the computer services to some extent, but there seems to be a threshold after which the use of the services had a more positive impact.

Educating patients at home. Community Health Rap.

OBJECTIVES: The authors analyzed the impact of home health education by studying the impact of a computer service called Community Health Rap. When patients call this service, the computer records their questions and alerts an expert who records a response. Subsequently, the computer alerts the patient that the question has been addressed. METHODS: Subjects included a group of 82 pregnant women who had used cocaine during or 1 month before pregnancy (as reported by the woman) and a group of residents of zip code areas with the lowest income in Cleveland. From the drug-using pregnant women, we collected data regarding satisfaction with Community Health Rap, usage of Community Health Rap per month, self-reported health status (using the General Health Survey), and the extent of drug use (using the Addiction Severity Index). Trained coders also classified the nature of questions posed to the Community Health Rap by either the pregnant women who abuse drugs or the members of target households. Among the pregnant women who abuse drugs, we compared the differences between those who used the service and those who did not. To control for baseline differences between the two groups, analysis of co-variance was used with exit values as the dependent variables, the baseline values as the co-variates, and participation in the Community Health Rap as the independent variable. RESULTS: Almost half (45%) of poor, undereducated subjects who lived in inner urban areas used the computer service. Content analysis of Community Health Rap messages revealed that subjects had many questions that were of a social nature (regarding sex, relationships, etc), in addition to medical questions. Analysis showed that poor health status, more frequent drug use, lower education, and age did not affect regular use of Community Health Rap service. No health outcomes or utilization of treatment were associated with regular use of Community Health Rap. One exception, however, was that regular users of Community Health Rap reported slower improvement of their pain than those who did not use Community Health Rap. CONCLUSIONS: These data suggest that expansion of information services to households will not leave the poor and the undereducated population groups "behind." They will use computer services, though such services may not have an impact on their health status or cost of care.

Electronic self-help and support groups.

OBJECTIVES: The authors examined the impact of a voice bulletin board on the following: (1) participation in self-help efforts, (2) expression of emotional support, (3) development of solidarity within the group, (4) utilization of health-care services, and (5) health status of subjects. METHODS: Subjects were 53 pregnant women who abused drugs. A quasi-experimental design with matched control group and observations before and after intervention were carried out. Clients in the control group were asked to participate in biweekly face-to-face meetings. Clients in the experimental group participated in the voice bulletin board. Experimental subjects had previous experience with computer services. Subjects reported their level of drug use, health status, and utilization of health services. They also reported on their symptoms, attitudes toward use of physician services, loneliness, willingness to disclose information in groups, and sense of solidarity with their group. The content of the communication among the experimental group was recorded and the utterances were classified as to the type of communication. Exit interviews were done 4 months after baseline interviews were conducted. Clients were paid to complete the baseline and the exit questionnaires, and 94% completed the exit questionnaires. The dependent variables were utilization or health status at exit; the co-variate was utilization or health status at baseline; and the independent variable was the group in which the subject participated. RESULTS: Clients were eight times more likely to participate in the voice bulletin board than in the face-to-face meeting (alpha < 0.01). The majority of the comments left on the bulletin board (54.6%) were for emotional support of each other; no "flaming" or overt disagreements occurred. The more clients participated in the voice bulletin board, the more they felt a sense of solidarity with each other (alpha < 0.001). Members of the experimental group reported significantly lower rates of visiting outpatient clinics than members of the control group (alpha < 0.05). Lower utilization did not lead to poor health status or more drug use: There were no statistically significant differences in the health status and drug use between the experimental and the control groups. CONCLUSIONS: Voice bulletin boards may be an effective method of providing support to mothers who have a history of drug use. Use of these services may lead to lower cost without worsening patients' health.

A review of factors affecting treatment outcomes: Expected Treatment Outcome Scale.

The Expected Treatment Outcome Scales was developed to gather information on clients who abuse drugs or alcohol, to assess their severity of illness, and to evaluate the effectiveness of drug treatment in nonrandomized clinical studies. The scale is based upon a multiattribute value model reflecting the opinions of an expert panel. The experts identified 25 variables, or predictors of relapse, from which 48 questions were constructed. Answers to the questions are individually scored. These scores are summed to produce an overall Expected Treatment Outcome score. This paper focuses on the development and preliminary validation of the Expected Treatment Outcome Scale. Results of our analysis show a correlation of .89 between the experts' average ratings of hypothetical clients and scores based on our scale. This finding suggests that the Expected Treatment Outcome Scale has face validity and accurately simulates the experts' judgments regarding treatment outcome. Further research is necessary to assess the reliability as well as the concurrent and predictive validity of our instrument.

Injection drug users in the Midwest: an epidemiologic comparison of drug use patterns in four Ohio cities.

Variations in the drug use patterns of injection drug users (IDUs) can have important implications for public health efforts aimed at reducing drug abuse and the transmission of the human immunodeficiency virus. This article describes and compares the characteristics of IDUs living in four Ohio cities and compares African-American and White IDUs at a statewide level. Data from 2,001 IDUs who were recruited for the National AIDS Demonstration Research project between 1989 and 1991 in Columbus, Cleveland, Cincinnati, and Dayton were compared on a number of variables by city and by ethnicity using descriptive statistics and ANCOVA analysis. Significant differences among IDUs in the four cities exist for the use of alcohol, marijuana, cocaine, crack, heroin, speedball, other opioids, shooting gallery use, "safer" needle practices, treatment history, and self-help participation. Differences by ethnicity emerged on all variables except marijuana use, overall injection frequency, and incarceration experience. The results suggest that dramatic differences exist between African-American and White IDUs, and among IDUs in cities relatively close together, regardless of ethnicity. These findings should be considered when developing policy and programs for prevention and treatment activities targeting IDUs.