Drug treatment effectiveness: African-American culture in recovery.

African-Americans are overrepresented among drug abusers in the United States when compared to European-Americans, and have lower rates of recovery from drug addiction after treatment. There has been no comprehensive research to date to specifically explain either this overrepresentation or lower rates of recovery among African-Americans. In this article, it is suggested that one reason for this lack of attention is due to the failure of drug abuse treatment providers and researchers to see race as a cultural rather than physical phenomenon. The point is made that cultural factors are intrinsic to successful efforts to address drug abuse among African-Americans. Several historic African-American coping strategies are outlined and shown to be powerful factors in client addictive behavior and barriers to recovery. Through case studies of clients who were successful in their effort to recover, the necessity to address cultural as well as personal issues is shown to be vital to successful recovery among African-Americans.

Prevention of HIV infection in street-recruited injection drug users. The Collaborative Injection Drug User Study (CIDUS).

BACKGROUND: Injection drug users (IDUs) and their sex partners account for an increasing proportion of new AIDS and HIV cases in the United States, but public debate and policy regarding the effectiveness of various HIV prevention programs for them must cite data from other countries, from non-street-recruited IDUs already in treatment, or other programs, and from infection rates for pathogens other than HIV. METHODS: Participants were recruited from the street at six sites (Baltimore [Maryland], New York [two sites], Chicago [Illinois], San Jose [California], Los Angeles [California], and at a state women's correctional facility [Connecticut]), interviewed with a standard questionnaire, and located and reinterviewed at one or more follow-up visits (mean, 7.8 months later). HIV serostatus and participation in various programs and behaviors that could reduce HIV infection risk were determined at each visit. RESULTS: In all, 3773 participants were recruited from the street, and 2306 (61%) were located and interviewed subsequently. Of 3562 initial serum specimens, 520 (14.6%) were HIV-seropositive; at subsequent assessment, 19 people, all from the East Coast and Chicago, had acquired HIV. Not using previously used needles was substantially protective against HIV acquisition (relative risk [RR], 0.29; 95% confidence interval [CI], 0.11-0.80 ) and, in a multivariate model, was significantly associated with use of needle and syringe exchange programs (adjusted odds ratio [ORadj], 2.08; 95% CI, 1.15-3.85). Similarly, reduction of injection frequency was very protective against seroconversion (RR, 0.33; 95% CI, 0.14-0.80), and this behavior was strongly associated with participation in drug treatment programs (ORadj, 3.54; 95% CI, 2.50-5.00). In a separate analysis, only 37.5% of study-participants had sufficient new needles to meet their monthly demand. CONCLUSIONS: In this large multicity study of IDUs in the United States, several HIV prevention strategies appeared to be individually and partially effective; these results indicate the continued need for, and substantial gaps in, effective approaches to preventing HIV infection in drug users.

The high-risk sexual practices of crack-smoking sex workers recruited from the streets of three American cities. The Multicenter Crack Cocaine and HIV Infection Study Team.

BACKGROUND AND OBJECTIVES: Small ethnographic and clinic-based studies indicate that crack-smoking sex workers are at high risk for human immunodeficiency virus (HIV) and sexually transmitted diseases (STD). STUDY GOALS: To examine the prevalence of risky sexual behaviors and HIV and STD in a large sample of street-recruited crack-smoking sex workers. STUDY DESIGN: From 1991 to 1992, 419 crack-smoking sex workers were recruited from urban neighborhoods, interviewed, and serologically tested. RESULTS: Many female and male sex workers reported sex with injectors (30% to 41%) or HIV-infected persons (8% to 19%), past STD (73% to 93%), and inconsistent condom use (> 50% for all types of sex). Sex workers who worked in crack houses or vacant lots, were paid with crack, or injected drugs had the riskiest sex practices. Most sex workers initiated sex work before they first smoked crack. More than 25% were infected with HIV (27.9%), syphilis (37.5%), or herpes simplex virus type 2 (66.8%). CONCLUSIONS: Interventions to prevent HIV/STD transmission among crack-smoking sex workers are urgently needed.

Background to crack cocaine addiction and HIV high-risk behavior: the next epidemic.

BACKGROUND: Increasing rates of sexually transmitted diseases among users of noninjection drugs prompt speculation that crack cocaine users who do not inject are at particularly high risk of HIV (human immunodeficiency virus) infection. METHODS: A street recruitment technique was employed to enroll 331 primarily African-American men aged 18-29 in an area of San Francisco where crack cocaine is sold openly. One-half were regular crack users and the other half had never used the drug. Few reported injection drug use or male-to-male sex. In a face-to-face interview, participants reported on their drug use, knowledge of HIV, sexual practice, condom use, and demographic characteristics. Following counseling, each was tested for HIV and syphilis. RESULTS: Comparisons showed that demographically similar, crack users reported more sexual partners in the last 12 months, more sexually transmitted diseases (STDs) in their lifetime, and greater frequencies of paying for sex, exchanging sex for drugs, and having sex with injection drug users. Users reported greater current depression, anxiety, and social isolation. They reported earlier initiation into alcohol use and less positive parenting experiences during their adolescence. CONCLUSION: These results are consistent with findings that report the comorbidity of drug abuse and mental illness. Implications are drawn for reducing HIV infection among this high-risk population for early adolescent, community mental health, and substance abuse treatment programs.

Crack cocaine smokers who turn to drug injection: characteristics, factors associated with injection, and implications for HIV transmission. The Multicenter Crack Cocaine and HIV Infection Study Team.

A survey of 1220 street-recruited crack cocaine smokers revealed that crack smokers may turn to drug injection to ease crack withdrawal. Crack smokers who later injected tended to smoke crack more heavily and for longer periods than those who did not inject. The initiation of injection was significantly associated with ever snorting heroin (prevalence ratio [PR] = 3.4, 95% confidence interval [CI] = 2.0-5.9) or snorting heroin specifically while smoking crack (PR = 2.3, 95% CI = 1.3-4.0), suggesting that snorted heroin use may mediate the transition to injection among crack smokers. Programs to prevent and treat crack dependence may prevent later injection and injection-related infections including HIV.

Intersecting epidemics--crack cocaine use and HIV infection among inner-city young adults. Multicenter Crack Cocaine and HIV Infection Study Team.

BACKGROUND AND METHODS: The smoking of "crack" cocaine is thought to be associated with high-risk sexual practices that accelerate the spread of infection with the human immunodeficiency virus (HIV). We studied 2323 young adults, 18 to 29 years of age, who smoked crack regularly or who had never smoked crack. The study participants, recruited from the streets of inner-city neighborhoods in New York, Miami, and San Francisco, were interviewed and tested for HIV. This report presents the findings for the 1967 participants (85 percent) who had never injected drugs. RESULTS: Of the 1137 crack smokers, 15.7 percent were positive for HIV antibody, as compared with 5.2 percent of the 830 nonsmokers (prevalence ratio adjusted for the city, 2.4; 99 percent confidence interval, 1.7 to 3.6). The prevalence of HIV was highest among the crack-smoking women in New York (29.6 percent) and Miami (23.0 percent). Of the 283 women who had sex in exchange for money or drugs, 30.4 percent were infected with HIV as compared with 9.1 percent of the 286 other women (prevalence ratio, 3.1; 99 percent confidence interval, 1.9 to 5.1); of the 91 men who had anal sex with other men, 42.9 percent were infected with HIV as compared with 9.3 percent of the 582 men who did not have anal sex with other men (prevalence ratio, 4.7; 99 percent confidence interval, 3.0 to 7.4). In multivariable analyses, these high-risk sexual practices accounted for the higher prevalence of HIV infection among the crack smokers, as compared with those who did not smoke crack. Women who had recently had unprotected sex in exchange for money or drugs were as likely to be infected as men who had had sex with men (40.9 percent vs. 42.9 percent). CONCLUSIONS: In poor, inner-city communities young smokers of crack cocaine, particularly women who have sex in exchange for money or drugs, are at high risk for HIV infection. Crack use promotes the heterosexual transmission of HIV.

High-risk sex behavior among young street-recruited crack cocaine smokers in three American cities: an interim report. The Multicenter Crack Cocaine and HIV Infection Study Team.

Since crack cocaine appeared in urban areas in the United States in the mid-1980s, reports have suggested that crack smokers may be at increased risk of sexually transmitted diseases (STDs), including infection with HIV, because they have multiple sex partners, trade sex for money or drugs, and rarely use condoms. A cross-sectional survey is being conducted in urban neighborhoods in Miami, New York and San Francisco--where crack use is common--to explore these issues. Indigenous street outreach workers are recruiting men and women who are either current regular crack smokers or who have never smoked crack; each group is further stratified according to whether participants had ever injected drugs. Participants were interviewed about their sexual and drug-use practices. Overall, crack smokers, whether injectors or not, engaged in higher-risk sexual behaviors than nonsmokers, reported greater numbers of sex partners than nonsmokers, and were more likely than nonsmokers to have exchanged sex for money or drugs or to have had an STD. Differences between crack smokers and nonsmokers were generally greater among non-injectors than among injectors, and generally greater among women than among men. Condom use, although somewhat more common with paying than nonpaying partners, was infrequent overall. Most of the subjects had not been in substance abuse treatment in the preceding 12 months, and a majority had never been in substance abuse treatment. Education and prevention programs specifically targeted at crack smokers not currently in substance abuse treatment are needed to reach these high-risk persons.

African-American culture and AIDS prevention. From barrier to ally.

African Americans make up an increasing proportion of persons with the acquired immunodeficiency syndrome (AIDS). I identify and describe cultural elements such as oral traditions, multiple naming, a collective identity, extended families, and sexuality influenced by myth and exaggeration that condition African Americans' reactions to AIDS prevention. I also offer suggestions on how these cultural elements can be used for effective AIDS prevention efforts in African-American communities.

Release of polyionizable compounds from submicrometer oil-in-water emulsions.

A novel, general, theoretical equation that describes the release of polyionizable compounds from submicrometer emulsions was derived and evaluated. The model accounts for simultaneous partitioning, interfacial activity, and adsorption to surfactant for n independent drug species and j surfactant species in a single emulsion system. Under the appropriate conditions, this model collapses to a previously described model for submicrometer emulsions. The model was tested for submicrometer emulsions containing a model dibasic compound (quinine sulfate). Drug release behavior was observed at pH 3.00, 5.07, and 7.50 in the presence and absence of an anionic surfactant (sodium lauryl sulfate). At each pH, the proposed theory describes the observed release behavior. At all pHs studied, a substantial amount of quinine was adsorbed to the surface of the oil droplet. Presumably, this behavior was largely the result of electrostatic attraction between ionized drug and sodium lauryl sulfate at the oil-water interface. Adsorption constants were evaluated for complexation of cationic and dicationic species of quinine to sodium lauryl sulfate, and the adsorption constant of the cationic species was larger, presumably because of the ionic nature of the surfactant.

Risk of sexually transmitted disease among black adolescent crack users in Oakland and San Francisco, Calif.

Crack cocaine is a smokable form of cocaine hydrochloride that has been associated with increases in admissions to drug treatment programs, and, recently, increases in the incidence of sexually transmitted diseases (STDs) among black teenagers. In an exploratory, cross-sectional study of the prevalence of risk behaviors that would promote the dissemination of STDs (including human immunodeficiency virus) among 222 black teenaged crack users, 41% of those interviewed reported a history of an STD. A history of an STD was more likely to be reported by girls (55%) than by boys (34%) and by those who combined crack use with sexual relations (51%) than those who did not (32%). The number of risk behaviors for STDs or human immunodeficiency virus reported by respondents (including failure to use a condom in one's most recent sexual encounter, having had a history of an STD, engaging in exchanges of sex for drugs or money, combining sexual activity with drug use, and reporting five or more sexual partners per year) was evaluated using multiple regression analysis stratified by gender. For girls, a history of selling crack and the number of reported risk behaviors (R = .46); for boys who chose the description "I don't know ahead of time if I'm going to have sex--it just happens" and the number of drugs used on a daily basis were associated with the number of reported risk behaviors (R = .31). Because of the impetuous nature of some crack-related sexual activity and because 76% of respondents acknowledged that they were either "very worried" or "somewhat worried" that they might get acquired immunodeficiency syndrome, it is possible that a program of widespread distribution of condoms in neighborhoods where crack use is prevalent might make it possible for the worried, impulsive crack user to practice "safer sex."

Crack users: the new AIDS risk group?

Crack cocaine, a smokable form of cocaine hydrochloride, is now widely available in American inner cities. Reports of high rates of unprotected sexual activity among crack users, coupled with reports of high rates of sexually transmitted diseases (STDs), have raised fears that this population of drug users may soon be contracting and disseminating sexually transmitted HIV. In a study of 205 black adolescent crack users conducted in Oakland and San Francisco, California, 101 respondents (49% of the sample) who reported using crack in combination with sexual activity were examined. Those respondents who reported having a history of one or more STD were compared using discriminant analysis (DA). A successful discrimination (canonical correlation = 0.61, p = 0.000) identified five variables that distinguished those with a STD history from those with no STD history: gender (being female) (p = 0.000), frequency of marijuana use (p = 0.005), response to the question; "Do you plan for sex or does it just happen?" (p = 0.002), response to the statement, "I use drugs to get away from my problems" (0.029), and response to the question, "Do you agree that sex doesn't feel as good when you use a condom?" (p = 0.006). The selection of these variables was thought to represent an underlying passivity in the way that crack users who combine crack use with sex approach sexual activity.

Crack and AIDS: an ethnographic impression.

To date, there are no scientific studies describing the "crack" epidemic, yet the observations reported here suggest that understanding the crack epidemic is urgent. As a cheap, highly addictive drug, crack increases risk for human immunodeficiency virus infection and could have devastating implications for many communities around the country.

Obturator nerve block for painful hip in adult cerebral palsy.

Nearly 25% of patients with severe spastic cerebral palsy (CP) develop hip dislocations/subluxations which may become painful. Three patients with spastic CP and painful hip dislocations/subluxations, who were poor surgical candidates and were unresponsive to conservative medical management, underwent obturator nerve block which resulted in temporary relief of pain and improved their activities of daily living. There were no known complications from this procedure.

Outpatient rehabilitation for chronic neuromuscular diseases.

Cost-conscious outpatient rehabilitation of 210 patients in a neuromuscular disease clinic was examined. The patients followed over a one-year period included: Duchenne Muscular Dystrophy, [50], Charcot-Marie-Tooth [42], Limb-Girdle Dystrophy [37], Spinal Muscular Atrophies [28], "Congenital" Myopathies [12], Friedreich's Ataxia [7], Polymyositis [7] and other related diseases. The 210 patients were profiled by age, sex, family history, and age at onset of symptoms. The rehabilitation of each patient was examined for ancillary service utilization such as pulmonary [11%], orthopedic [10%], and social services consultations [43%], formal occupational [7%] and physical therapy sessions [6%]. Rehabilitation costs were computed for each patient and each disease. "Rehabilitation Costs" included: equipment, laboratory fees, physician fees, building use, medications, travel, and P.T., O.T. and social service charges. Equipment expenditures were the major portion of rehabilitation, determined to be 70% of the annual costs. Because equipment was determined to be the overwhelming "rehabilitation" expense, the types of equipment prescribed for each disease were also defined. Laboratory testing was the next most costly category, resulting in 11% of the overall cost. Physician fees were determined to be only 8% of annual rehabilitation costs. The total mean per capita cost of outpatient rehabilitation was $750 per year, with a range of from $200 per year for Myotonic Dystrophy to $1200 per year for Duchenne Muscular Dystrophy. This study indicates that annual per capita "Rehabilitation Costs" in an outpatient neuromuscular disease clinic are surprisingly inexpensive when one considers the extent of disability in these diseases.

Spontaneous unilateral pulmonary edema.

A patient presented with wheezing, evidence of vascular congestion on physical examination, and leukocytosis. A chest x-ray film suggested pneumonia. When unilateral pulmonary edema was revealed on a repeat chest film, the patient was given diuretic therapy and responded favorably. This case thus differs from the usual pattern of symmetrical homogeneous density on the chest roentgenogram in pulmonary edema of cardiac origin.

Fluidotherapy and exercise in the management of sickle cell anemia. A clinical report.

Children hospitalized during sickle cell anemia crises suffer restricted range of motion secondary to vasoocclusive-induced pain and are almost always nonambulatory. Texas Children's Hospital, Houston, TX, now refers most of these children to the Physical Therapy Department at St. Luke's Episcopal Hospital, Houston, TX, for Fluidotherapy and general strengthening and increased endurance programs. The Fluidotherapy treatment and the exercise program have resulted in a marked reduction in the length of hospitalization (compared with length of hospitalization by the same patients during previous episodes) and have permitted a major reduction in the dosage of analgesics previously administered. Spine, trunk, and extremity range of motion and gait improved markedly with treatment.

The effects of sodium nitroprusside on the hemodynamics of burn shock: results of an experimental sheep model.

A low cardiac output state is observed following major thermal injury in both experimental and clinical settings. The major determinants of cardiac output are preload, afterload, and the contractile state of the myocardium. The effects of afterload reduction in acute thermal injury are the focus of this experiment. Pure-bred young nonpregnant ewes of the Suffolk strain were utilized to determine the effect of afterload reduction on the cardiac index in experimental burn shock. Four groups of animals were studied; Group 1: unburned control (n = 5); Group 2: unburned-treated with sodium nitroprusside (n = 5); Group 3: 40% burned (n = 9); and Group 4: 40% burned-treated with sodium nitroprusside (n = 9). Pulmonary arterial, intravenous, and bladder catheters were placed in all animals. Following anesthesia with or without a burn, the animals were monitored for 24 hours. Measured and calculated parameters included cardiac index, pulmonary arterial and arterial pressures, pulmonary and systemic vascular resistance indices, shunt, arterial and mixed venous blood gases and pH, and hematocrit. When burned animals with and without nitroprusside were compared, significantly higher cardiac indices, expressed as per cent of baseline, were noted for the sodium nitroprusside-treated group at 8 and 12 hours postburn. The burned-treated animals' cardiac index was not significantly different from control animals' at 8 hours postburn. However, the burned-untreated animals had significantly depressed cardiac indices until 18 hours postburn.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of resuscitation with hypertonic vs. hypotonic vs. colloid on wound and urine fluid and electrolyte losses in severely burned children.

Thirty-nine children with large burns were resuscitated with either a hypertonic (HLS) (17 patients), hypotonic (11 patients), or colloid (11 patients) fluid regimen. Burn dressings, bed linen, and urine were analyzed for electrolyte content. The group receiving HLS excreted the greatest percentage of the administered sodium load in the urine, significantly more than the other two groups; however, the combined wound and urinary sodium losses were significantly greater for the group receiving colloid. Sodium loss through the burn wound exceeded urinary loss fivefold in the colloid group. The volume of fluid lost across the burn wound was inversely related to the osmolality of the fluid used for resuscitation. Wound sodium loss was a function of both sodium and fluid load. The flux of fluid and electrolytes across the burn wound is a dynamic part of the resuscitation problem and is dramatically effected by the volume and concentration of fluid used.

Statistical methods to predict morbidity and mortality: self assessment techniques for burn units.

The medical records of 806 adult and paediatric burn patients were retrospectively reviewed. Patient data was summarized, coded and entered in a computer for subsequent analysis. This report describes the use of multiple regression analysis to produce equations useful for the prediction of the morbidity parameters: length of hospital stay, number of transfusions required and number of operative procedures. The multiple regression equations developed are useful as prediction tools, in patient medical audit and in assessing improvements in burn care. The classical technique of probit analysis for predicting the probability of mortality was used to develop the LA50's of burn injury. These LA50's were used as the basis for comparison of survival statistics between burned patients in this series and those registered in the National Burn Information Exchange (Feller, 1979). There is an apparent significantly improved survival in the children, young adults through 34 yrs and the older adults (60-74 yrs) in the current series of patients. This observation would support the adoption of the protocol of burn care used in treating these patients. The newer technique of discriminant analysis is also described. Discriminant analysis is a multifactorial method for discriminating between dichotomous outcomes (survivors and non-survivors). The technique of discriminant scoring proved to be 95.8 per cent accurate in predicting burn survival. Use of a burn severity scoring technique will also assist in recognition of the high risk patient.