Clinical characteristics and short-term outcomes of adult patients with urolithiasis: first report from Somalia.

OBJECTIVE: This study aimed to investigate the data of adult patients admitted to the only tertiary care center in Somalia with the diagnosis of urolithiasis and to present the first report from this Sub-Saharan African country. PATIENTS AND METHODS: This study was designed as a retrospective single-center study conducted in Somalia Turkiye Training and Research Hospital. Adult patients who received the diagnosis of urolithiasis and who were admitted to the urology department constituted the target population. Reviewed data included demographic parameters, stone features, type of surgical procedure, intraoperative and early postoperative complications, and inpatient mortality. RESULTS: Overall, 3,680 patients were admitted during the study period. Among these, 620 (17%) patients were admitted due to urolithiasis. There was a significant male predominance with a male-to-female ratio of 3.4:1. Urinary bladder was the most common stone location (n=253, 40.8%), followed by the kidney (n=223, 35.9%). The mean stone diameter was 22.41 (5-64); most (39.4%) of the patients had a stone diameter between 20 and 30 mm, while 27.5% had stones with diameters between 10 and 20 mm. Minimally invasive procedures were the primary surgical modality in 52.6% (n=326) of our patients. However, 45.9% (n=285) of the patients underwent open surgery. CONCLUSIONS: The rate of adults with urolithiasis is relatively high in Somalia, as in many other African countries, with a significant male predominance. Although open surgery is rarely used for treating adult urolithiasis in industrialized countries, this approach is still commonly used in Somalia, similar to other parts of Africa.

Our kidneys and teeth may be closer than we think: relationship between dental calculi and renal stone burden grading in a patient series from Somalia.

OBJECTIVE: This study investigated the correlation between dental calculi grading and renal stone burden grading. PATIENTS AND METHODS: This study was designed as an observational single-center study and included consecutive patients with radiologically confirmed renal stones at our center between January 2022 and July 2022. These patients were referred to the dentistry clinic for a dental examination to assess dental calculi and oral hygiene. Investigated parameters included demographic characteristics, renal stone location and diameter, urine pH, and dental evaluation findings (teeth brushing habits, oral hygiene, and dental calculi). Renal stone burden grade and dental calculi grade were calculated, and Spearman's rank-order correlation analysis was used for correlation analyses. RESULTS: Overall, 204 patients were included. The mean patient age was 36.3±15.2. Approximately half of the patients (49.2%) had multiple stones. About 36% of the participants had high-grade dental calculi, while 29.4% had intermediate low-grade dental calculi. Oral hygiene was significantly associated with dental calculi grade (p<0.001). The dental calculi grade was positively and moderately correlated with the renal stone diameter (Spearman's rho=0.493, p<0.001). Among patients with a renal stone diameter greater than 20 mm, intermediate to high-grade dental calculi were found in 88.4%. This proportion was 49.1% for those with a renal stone diameter smaller than 20 mm. CONCLUSIONS: Dentists should consider the presence of undiagnosed kidney stones in patients with especially intermediate or high-grade dental calculi. Urologists should know that patients with large and multiple kidney stones may have dental calculi.

The Q359K/T360K mutation causes cystic fibrosis in Georgian Jews.

BACKGROUND: The Q359K/T360K mutation, described in Jewish CF patients of Georgian decent, is of questionable clinical significance. METHODS: Clinical records of patients with the Q359K/T360K mutation from three CF centers were studied for phenotypic expression and putative mechanism of dysfunction. Computer models of mutant CFTR were constructed. RESULTS: Nine patients (4 homozygous) of Georgian Jewish origin were included. Age at diagnosis was 9.4 (0.25-38.2) years, median (range). Sweat chloride was 106 ±â€¯13 meq/L, mean ±â€¯SD. Nasal Potential Difference performed in three, was abnormal. All had pulmonary symptoms since early childhood and bronchiectasis. Median FEV1 was 88 (40-121)%. Five had chronic mucoid P. aeruginosa. Homozygous patients were pancreatic insufficient. Enzyme supplementation was initiated at 3.8 (1-14.7) years, median (range). Structural models hint at possible interference of this mutation with transmembrane chloride transport. CONCLUSION: In our cohort, the Q359K/T360K mutation resulted in a severe CF phenotype, although with residual early CFTR function. The CFTR2 database should consider defining this mutation as CF-causing.

Epicardial fat thickness is associated with severity of disease in patients with chronic obstructive pulmonary disease.

OBJECTIVE: Cardiovascular diseases (CVD) are common in patients with chronic obstructive pulmonary disease (COPD) and the BODE index is an important tool for the prognostic assessment of COPD patients. It is well known that epicardial fat thickness (EFT) is related to CVD. However, there are very few data about the relationship between EFT and BODE index. The aim of this study is to investigate the relationship between EFT and BODE index in patients with COPD. PATIENTS AND METHODS: We prospectively included 157 patients with COPD and 45 controls in the present study. All patients underwent pulmonary function tests and six-minute walking test. EFT and other echocardiographic parameters were measured using transthoracic echocardiography on admission. Patients were divided into four quartiles according to the BODE index scores (Quartile-1 (Q1): 0-2 points; Quartile-2 (Q2): 3-4 points; Quartile-3 (Q3): 5-6 points; Quartile-4 (Q4): 7-10 points). High sensitive C-reactive protein (Hs-CRP) and other biochemical parameters were measured in all participants. RESULTS: COPD patients had higher EFT values compared with control group (p<0.05). When COPD patients were classified according to BODE index quartiles, the highest EFT values were observed in Q1 compared with other quartiles (p<0.05, for all). EFT values showed a decreasing trend from Q1 to Q4. Furthermore, EFT was independently associated with BODE index (ß=0.405, p<0.001), Hs-CRP (ß=0.300, p<0.001) and diabetes (ß=0.338, p<0.001) in multivariate linear regression analysis. CONCLUSIONS: Our findings suggested that EFT is independently and negatively associated with the severity of disease as indicated by BODE index in patients with COPD.

The predictive effect of initial complete blood count of intensive care unit patients on mortality, length of hospitalization, and nosocomial infections.

OBJECTIVE: The mean platelet volume (MPV) can be used as an indicator of platelet activation. However, it has been shown that the platelet/lymphocyte ratio (PLR) can provide useful predictive information about inflammation and aggregation pathways. The neutrophil/lymphocyte ratio (NLR) may also be helpful as a marker of systemic or local inflammation. The main objective of this study evaluated to unselected critically ill patients the relationship of initial MPV, NLR, and PLR with mortality, length of hospitalization, and the risk of developing nosocomial infections in ICU patients. PATIENTS AND METHODS: In this retrospective study, we evaluated consecutive patients at our tertiary nine-bed ICU. One hundred seventy-three patients who were followed up during a 1-year period were included. RESULTS: MPV levels were found to be higher in patients who died in the hospital (p = 0.05). In addition, there was a significant positive correlation between expected mortality rate and MPV among non-survivors (p = 0.009). NLR levels were higher among non-survivors, but this difference was not statistically significant (p = 0.435). PLR levels were similar between non-survivors and survivors (p = 0.173). The initial NLR and PLR were significantly higher in patients with nosocomial infections. NLR and PLR had a significant positive correlation with length of hospitalization (p = 0.006 and p = 0.027, respectively). CONCLUSIONS: In our study, we found that high PLR and NLR may be indicators for the development of nosocomial infections. Moreover, the length of hospitalization may be prolonged in patients with high PLR and NLR.

Coronary collateral circulation in patients with chronic coronary total occlusion; its relationship with cardiac risk markers and SYNTAX score.

BACKGROUND: Compared to patients without a collateral supply, long-term cardiac mortality is reduced in patients with well-developed coronary collateral circulation (CCC). Cardiovascular risk markers, such as N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitive C-reactive protein (hs-CRP) and high-sensitive cardiac troponin T (hs-cTnT) are independent predictors for cardiovascular mortality. OBJECTIVES: The main goal of this study was to examine the relationship between CCC and cardiovascular risk markers. METHODS: We prospectively enrolled 427 stable coronary artery disease patients with chronic total occlusion (mean age: 57.5±11.1 years). The patients were divided into two groups, according to their Rentrop scores: (a) poorly developed CCC group (Rentrop 0 and 1) and (b) well-developed CCC group (Rentrop 2 and 3). NT-proBNP, hs-CRP, hs-cTnT, uric acid and other biochemical markers were also measured. The SYNTAX score was calculated for all patients. RESULTS: The patients in the poorly developed CCC group had higher frequencies of diabetes and hypertension (p<0.05 for both). Compared to the well-developed CCC group, the SYNTAX score, Hs-cTnT, hs-CRP, NT-proBNP, uric acid, neutrophil count and mean platelet volume (MPV) values were higher in patients with poorly developed CCC (p<0.05 for all). On multivariate logistic regression analysis, hs-cTnT (ß=0.658, 95% CI=0.589-0.735, p<0.001) and NT-proBNP (ß=0.991, 95% CI=0.987-0.995, p<0.001) as well as hs-CRP and diabetes were independent predictors of CCC. CONCLUSION: Cardiac risk markers, such as NT-proBNP, hs-cTnT and hs-CRP are independently associated with CCC in stable coronary artery disease with chronic total occlusion.

Gamma glutamyl transferase activity: relationship with thoracic aortic intima media thickness and inflammation.

OBJECTIVE: Increased serum gamma-glutamyl transferase (GGT) activity is known to be associated with atherosclerotic diseases. Thoracic aortic intima-media thickness (IMT) was reported as a marker of preclinical atherosclerosis. However, there is a lack of research directly examining the relationship between serum GGT activity and thoracic aortic IMT. Therefore, we aimed to investigate the association between serum GGT activity and thoracic aortic IMT. PATIENTS AND METHODS: The study population consisted of 329 patients without coronary artery disease, who underwent transesophageal echocardiography (TEE) examination for various indications from January 2011 to April 2013. GGT, high-sensitivity C-reactive protein (hs-CRP) and other biochemical markers were measured in all patients. The patients were classified into tertiles according to their GGT activities (GGTlow < 19 U/l, GGTmid ≥ 19 U/l < 29 U/l, and GGThigh ≥ 29). RESULTS: The highest aortic IMT values were observed in the GGThigh group compared with the GGTmid and GGTlow groups (p < 0.05, for all). Also, aortic IMT values in the GGTmid group were higher than in the GGTlow group (p < 0.05). Multivariate regression analysis showed that GGT activity was independently associated with aortic IMT (ß = 0.487, p < 0.001) hs-CRP (ß = 0.282, p < 0.001), and triglyceride level (ß = 0.161, p = 0.007). CONCLUSION: The higher serum GGT concentrations within the "normal" range were associated with a greater IMT of the thoracic aorta. GGT activity may be a predictor of the extent of subclinical aortic atherosclerosis assessed with thoracic aortic IMT.

Global motions exhibited by proteins in micro- to milliseconds simulations concur with anisotropic network model predictions.

The Anton supercomputing technology recently developed for efficient molecular dynamics simulations permits us to examine micro- to milli-second events at full atomic resolution for proteins in explicit water and lipid bilayer. It also permits us to investigate to what extent the collective motions predicted by network models (that have found broad use in molecular biophysics) agree with those exhibited by full-atomic long simulations. The present study focuses on Anton trajectories generated for two systems: the bovine pancreatic trypsin inhibitor, and an archaeal aspartate transporter, GltPh. The former, a thoroughly studied system, helps benchmark the method of comparative analysis, and the latter provides new insights into the mechanism of function of glutamate transporters. The principal modes of motion derived from both simulations closely overlap with those predicted for each system by the anisotropic network model (ANM). Notably, the ANM modes define the collective mechanisms, or the pathways on conformational energy landscape, that underlie the passage between the crystal structure and substates visited in simulations. In particular, the lowest frequency ANM modes facilitate the conversion between the most probable substates, lending support to the view that easy access to functional substates is a robust determinant of evolutionarily selected native contact topology.

NT-proBNP is associated with SYNTAX score and aortic distensibility in patients with stable CAD.

OBJECTIVE: A high N-terminal pro-brain natriuretic peptide (NT-proBNP) level provides significant prognostic information on patients with coronary artery disease (CAD). It is unclear whether aortic distensibility (AD), which reflects the aortic stiffness, and the extent and complexity of CAD, assessed with the SYNTAX score (SS), affect the secretion of NT-proBNP in stable CAD. We aimed to investigate the relationship between NT-proBNP levels and AD as well as with the extent and complexity of CAD in stable CAD patients. METHODS: The study included 411 patients with stable CAD (mean age = 61.7 ± 9.9 years, male/female = 247/164). The patients were divided into two groups according to the median NT-proBNP value (NT-proBNPlow group < 114 pg/ml and NT-proBNPhigh group ≥ 114 pg/ml). AD was calculated from the echocardiographically derived ascending aorta diameters and hemodynamic pressure measurements. Coronary angiography was performed and SS was determined in all patients. NT-proBNP and other biochemical markers were measured in all subjects. RESULTS: The AD and ejection fraction values of the NT-proBNPhigh group were lower and their SS levels were higher compared with those from the NT-proBNPlow group (p < 0.05, for all). The NT-proBNP level was independently associated with AD (ß = -0.378, p < 0.001), SS (ß = 0.262, p < 0.001), and ejection fraction (ß = - 0.295, p < 0.001) on multiple linear regression analysis. CONCLUSION: NT-proBNP was independently associated with an impaired elastic property of the aorta and with the extent and complexity of CAD as well as with left ventricular systolic dysfunction.

Serum uric acid and slow coronary flow in cardiac syndrome X.

OBJECTIVE: It has been recently shown that cardiac syndrome X (CSX) patients with slow coronary flow (SCF) have a worse long-term prognosis than those with normal coronary flow. Increased uric acid levels were shown to be associated with atherosclerosis, oxidative stress, and endothelial dysfunction. The purpose of the study was to investigate the relationship between coronary flow assessed with TIMI frame count (TFC) and serum uric acid (SUA) levels in patients with CSX. METHODS: The study population consisted of 113 consecutive patients with typical cardiac CSX and 41 controls without cardiac CSX. Frequencies of risk factors as well as biochemical and hematological data were recorded for all participants. Coronary blood flow was evaluated by TFC. All patients with a TFC greater than two standard deviations from the published normal range for any one of the three vessels were accepted as having slow coronary flow (SCF group), while those whose TFC values fell within the standard deviation of the published normal range for all of the three vessels were considered to have normal coronary flow. RESULTS: Of the 113 CSX patients enrolled, 40 (35.4%) had SCF. The mean TFC value was strongly positively correlated with SUA level, but weakly correlated with male sex, hypertension, diabetes, smoking, serum creatinine level, and hemoglobin. Multivariate regression analysis showed that only the SUA level was independently associated with SCF. The cut-off value for uric acid obtained by the ROC curve analysis was 4.55 mg/dl for the prediction of SCF (sensitivity, 77.5%; specificity, 73.6%). CONCLUSION: The SUA level is independently associated with SCF in patients with CSX.

A wavelet packet adaptive filtering algorithm for enhancing manatee vocalizations.

Approximately a quarter of all West Indian manatee (Trichechus manatus latirostris) mortalities are attributed to collisions with watercraft. A boater warning system based on the passive acoustic detection of manatee vocalizations is one possible solution to reduce manatee-watercraft collisions. The success of such a warning system depends on effective enhancement of the vocalization signals in the presence of high levels of background noise, in particular, noise emitted from watercraft. Recent research has indicated that wavelet domain pre-processing of the noisy vocalizations is capable of significantly improving the detection ranges of passive acoustic vocalization detectors. In this paper, an adaptive denoising procedure, implemented on the wavelet packet transform coefficients obtained from the noisy vocalization signals, is investigated. The proposed denoising algorithm is shown to improve the manatee detection ranges by a factor ranging from two (minimum) to sixteen (maximum) compared to high-pass filtering alone, when evaluated using real manatee vocalization and background noise signals of varying signal-to-noise ratios (SNR). Furthermore, the proposed method is also shown to outperform a previously suggested feedback adaptive line enhancer (FALE) filter on average 3.4 dB in terms of noise suppression and 0.6 dB in terms of waveform preservation.

Anharmonicity, mode-coupling and entropy in a fluctuating native protein.

We develop a general framework for the analysis of residue fluctuations that simultaneously incorporates anharmonicity and mode-coupling in a unified formalism. We show that both deviations from the Gaussian model are important for modeling the multidimensional energy landscape of the protein Crambin (1EJG) in the vicinity of its native state. The effect of anharmonicity and mode-coupling on the fluctuational entropy is in the order of a few percent.

A source separation approach to enhancing marine mammal vocalizations.

A common problem in passive acoustic based marine mammal monitoring is the contamination of vocalizations by a noise source, such as a surface vessel. The conventional approach in improving the vocalization signal to noise ratio (SNR) is to suppress the unwanted noise sources by beamforming the measurements made using an array. In this paper, an alternative approach to multi-channel underwater signal enhancement is proposed. Specifically, a blind source separation algorithm that extracts the vocalization signal from two-channel noisy measurements is derived and implemented. The proposed algorithm uses a robust decorrelation criterion to separate the vocalization from background noise, and hence is suitable for low SNR measurements. To overcome the convergence limitations resulting from temporally correlated recordings, the supervised affine projection filter update rule is adapted to the unsupervised source separation framework. The proposed method is evaluated using real West Indian manatee (Trichechus manatus latirostris) vocalizations and watercraft emitted noise measurements made within a typical manatee habitat in Florida. The results suggest that the proposed algorithm can improve the detection range of a passive acoustic detector five times on average (for input SNR between -10 and 5 dB) using only two receivers.

Relationship between myocardial performance index and aortic distensibility in patients with essential hypertension.

We aimed to investigate the association between aortic distensibility (AD) and left ventricle myocardial performance index (MPI) in patients with newly diagnosed hypertension (HT). We studied 49 patients with HT and 24 healthy control subjects. AD was calculated from the echocardiographically derived ascending aorta diameters. The MPI was calculated from both conventional flow Doppler echocardiography and tissue Doppler echocardiography recordings. Conventional Doppler E/A and tissue Doppler derived Ea/Aa were determined for all the subjects. Aortic distensibility was lower, and both conventional and tissue Doppler MPI values were higher (p<0.001 for all) in patient group compared with control group. AD was correlated with systolic blood pressure (SBP) (beta=-0.436, p=0.037), Ea/Aa (beta=0.228, p=0.038) and tissue derived MPI (beta=-0.302, p=0.043) in multiple linear regression analysis. Aortic distensibility was independently related to tissue derived MPI and Ea/Aa besides SBP.

Relationship between impaired elastic properties of aorta with left ventricle geometric patterns and left ventricle diastolic functions in patients with newly diagnosed essential hypertension.

The aim of this study was to investigate the association between elastic properties of aorta with left ventricle (LV) geometric patterns and LV diastolic functions in patients with newly diagnosed hypertension (HT). We studied 149 patients with newly diagnosed HT and 29 healthy control subjects. Echocardiographic examination was performed to all subjects. Ascending aorta (Ao) diameters (mm/m2) and Ao elastic indexes - namely, Ao strain [AS] (%), Ao distensibility [AD] (cm2 dyn(-1) x 10(-6)) were calculated. Four different geometric patterns were identified in hypertensive patients according to LV mass index (LVMI) and relative wall thickness (RWT). Tissue Doppler-derived Ea/Aa was determined from the all subjects. Patients vs. control subjects had lower mean AS and AD (p < 0.001 for both). Mean AS and AD of all geometric patterns significantly decreased compared with control group (p < 0.05 for all). Both AS and aortic AD of concentric remodelling (CR; p = 0.017 for both) and concentric hypertophic groups (p < 0.001 for both) were decreased compared with normal LV group. AS and AD of concentric hypertrophic pattern was lower than that of the CR group (p = 0.011 and 0.020 respectively) and the eccentric hypertrophic group (p < 0.001 and p = 0.002, respectively). Both AS and AD of the CR group were similar to that of the eccentric hypertrophic group (p > 0.05 for both). Both AS and AD were significantly correlated with age (beta = -0.178, p = 0.025, beta = -0.158, p = 0.029 respectively), LVMI (beta = -0.223, p = 0.022, beta = -263, p = 0.003 respectively), RWT (beta = -0.196, p = 0.019, beta = -0.189, p = 0.013 respectively) and Ea/Aa (beta = 0.174, p = 0.045, beta = 0.247, p = 0.002 respectively) in multiple linear regression analysis. Elastic properties of aorta were impaired in newly diagnosed HT. The degree of this impairment is different among various LV geometric patterns. In addition, impaired elastic properties of aorta were associated with RWT, LVMI and diastolic disfunctions, besides age, but not with LV geometry.

Paraoxonase and arylesterase activities in coronary artery disease.

BACKGROUND: Paraoxonase-1 is an enzyme with three activities which are inversely related to cardiovascular diseases. Accordingly, the aim of the study was to investigate the paraoxonase, arylesterase activities and oxidative/anti-oxidative status in coronary artery disease (CAD) and their correlation with the extent of CAD. MATERIALS AND METHODS: Study populations of 193 patients with angiographically documented CAD, 83 patients with normal coronary angiograms (NCAD) and 55 healthy volunteers were included in the study. The patients with CAD were divided into three categories according to the number of diseased coronaries. Also, a Gensini score was calculated for each patient. Serum paraoxonase and arylesterase activities were measured spectrophotometrically. Oxidative and anti-oxidative status was evaluated by measuring serum lipid hydroperoxide (LOOH), total anti-oxidant status (TAS) and free sulfhydryl groups (-SH = total thiol). Lipid parameters were determined by routine laboratory methods. RESULTS: Serum paraoxonase and arylesterase activities, TAS and -SH levels were lower in the CAD group compared with the NCAD group and control group (P < 0.05, all). Serum LOOH levels of the CAD group were greater than those in both the control and NCAD groups (P < 0.05). The major decreases in paraoxonase, arylesterase activities, -SH and TAS levels and the major increase in LOOH levels were observed in the 3-vessels disease group. In multiple linear regression analysis, the Gensini score was independently correlated with paraoxonase activity (beta = -0.469, P < 0.001), -SH levels (beta = -0.232, P < 0.001), HDL levels and history of diabetes. CONCLUSIONS: Both paraoxonase activity and -SH levels are independently associated with the presence and extent of CAD. Reduced paraoxonase activity and -SH levels may play a role in the severity of coronary atherosclerosis.

DNA damage in metabolic syndrome and its association with antioxidative and oxidative measurements.

The purpose of this study was to assess DNA damage levels in subjects with metabolic syndrome (MetS). Sixty-five subjects with MetS and 65 controls were enrolled in this study. Levels of DNA damage, total antioxidant capacity (TAC), total peroxide and oxidative stress index (OSI) were measured. We found that DNA damage levels were significantly increased [155.5 (60-264) vs. 93.2 (0-208) arbitrary units; p < 0.001] and TAC levels were significantly decreased in MetS than in control (1.34 +/- 0.27 vs. 55 +/- 0.33 mmol Trolox equivalent/l; p < 0.001). A significant falling trend in TAC levels and a significant rising trend in DNA damage values with the increase in the number of metabolic disturbances (anova p < 0.001 for both) were observed. Total peroxide (30.9 +/- 4.9 vs. 21.3 +/- 2.5 micromol H2O2/l; p < 0.001) and OSI levels [2.4 (1.3-3.8) vs. 1.4 (0.7-2.3) arbitrary units; p < 0.001] were significantly higher in the subjects with MetS than in controls. We found significant negative correlation between DNA damage and TAC levels in MetS (r = -0.656, p < 0.001) and in control (r = -0.546, p < 0.001). In multiple linear regression analysis, age, body mass index, presence of MetS and number of the components of MetS were independent predictors of log-transformed DNA damage (p < 0.05, for all). DNA damage is increased in patients with MetS. The increase in DNA damage might be occur because of the increase in the imbalance between the production of oxidants and antioxidant defences in subjects with MetS.

Religiousness and substance use in children of opiate addicts.

PURPOSE: To investigate among children of opiate addicts a potential protective effect of religiousness (broadly defined in the literature to include religious beliefs, practice, and tradition) against onset of substance use. METHODS: Subjects were 161 opiate-addicted biological parents recruited from methadone maintenance programs in the New York metropolitan area, their 279 children, and 63 non-opiate-addicted parents with whom the child had daily contact. Childhood onset of substance use was assessed using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS); parental DSM-III-R diagnosis of opiate addiction was assessed using the SADS-Lifetime Version (SADS-L). RESULTS: Religiousness in children of opiate addicts was associated with a substantially decreased likelihood of onset of substance use. Parent-child concordance of religiousness showed additional protective qualities with respect to religious denomination in opiate-addicted parent and with respect to the personal importance of religion and frequent attendance of religious services in non-opiate-addicted parents. CONCLUSION: Religiousness protects against substance use among children of opiate addicts.