Clinical and pathologic differences in interstitial lung disease based on antisynthetase antibody type.

BACKGROUND: Interstitial lung disease (ILD) is a common extramuscular manifestation of the idiopathic inflammatory myopathies (IIMs), dermatomyositis (DM) and polymyositis (PM). Patients with antisynthetase antibodies (ASA) demonstrate some or all of the features of the antisynthetase syndrome including IIM and ILD. It has been hypothesized that the clinical expression of antisynthetase syndrome varies between specific ASAs. OBJECTIVE: We sought to determine whether the myositis-associated ILD (MA-ILD) phenotype differs based on the presence of ASAs and by ASA subtype. METHODS: A cross-sectional and longitudinal analysis of consecutive patients enrolled at the Johns Hopkins Myositis Center with ILD in the setting of clinically diagnosed autoimmune myositis was conducted. RESULTS: Seventy-seven subjects were included; 36 were ASA negative, 28 were anti-Jo1 positive, and 13 were non-Jo1 ASA positive (5 anti-PL-12, 4 anti-PL-7, 2 anti-EJ, and 2 anti-OJ). Non-Jo1 ASA positive participants were more likely to be African-American than Caucasian as compared to both the anti-Jo1 positive (p = 0.01) and ASA negative groups (p < 0.01). ASA negative participants had better mean forced vital capacity percent predicted (FVC%) and total computed tomography scores over time compared to those with anti-Jo1 after controlling for potential confounders. CONCLUSIONS: ASA status was significantly different by race. Those with anti-Jo1 antibodies had worse lung function and CT scores over time compared to those without detectable antisynthetase antibodies. Further prospective study in a larger cohort is needed to determine whether these apparent antibody-specific differences in demographics and manifestations of disease translate into meaningful disparities in clinical outcomes.

First-trimester Down syndrome screening using additional serum markers with and without nuchal translucency and cell-free DNA.

OBJECTIVE: This study aimed to evaluate serum-only four-marker first trimester (1T-Quad) Down syndrome screening, alone or contingently to select 10-20% with highest risk for nuchal translucency (NT) or cell-free (cf)DNA. METHODS: Stored maternal serum samples (-80 °C) from 90 pregnancies with fetal Down syndrome and 1607 controls were retrieved and measured for placental growth factor, α-fetoprotein, pregnancy-associated plasma protein and free ß-human chorionic gonadotropin. Samples were from singleton pregnancies (9-13 + 6 weeks), and NT was measured between 11 and 13 + 6 weeks. Markers were expressed in multiples of the normal median (MoM) for gestation. Gaussian models were fitted to the distribution of log MoMs by using observed parameters, standardized maternal age distribution (mean 27, SD 5.5) and published cfDNA results. RESULTS: The model-predicted detection rate (DR) for 1T-Quad was 74% [5% false-positive rate (FPR)]. When used contingently to select for NT, the DR was 89% at 5%. When used to select for cfDNA, the DR was 91% (FPR < 0.05%). CONCLUSION: The 1T-Quad test can achieve a similar DR to a second-trimester Quad test. When used contingently to select for NT, the DR is similar to the Combined test. Used contingently to select for cfDNA would achieve even higher detection.

Reducing alcohol consumption among heavily drinking women: evaluating the contributions of life-skills training and booster sessions.

Problem-drinking women (N = 144) without histories of severe physical dependence on alcohol received drinking-reduction training and were assigned to receive (or not receive) 2 treatment enhancements: life-skills training and booster sessions. The design resulted in 4 treatment conditions: drinking-reduction treatment (DRT) plus life-skills training, DRT plus booster sessions, DRT plus life-skills training and booster sessions, or DRT only. The interventions entailed 13 hr of DRT, 7 hr devoted to the life-skills training or to a no-life-skills training educational module, plus 8 hr of booster sessions for those receiving them. Participants evidenced significant reductions in alcohol use during the 18 months after treatment. Those with greater pretreatment drinking evidenced differential response to the experimental manipulations: The treatment enhancements (life skills and booster sessions) led to significantly improved drinking outcomes among women who were heavier drinkers at pretreatment. There were no significant effects of the treatment enhancements among lighter drinkers at pretreatment. The results provide support for use of treatment enhancements in interventions designed to moderate women problem drinkers' alcohol use.

Association between congenital foot anomalies and gestational age at amniocentesis.

OBJECTIVES: Our objectives were to confirm the reported association between early amniocentesis and congenital foot anomalies as well as to report, for the first time, on the outcome of amniocenteses performed during the 13th and 14th weeks of gestation. METHODS: We conducted a triple cohort retrospective study of 4457 amniocenteses. Cohort definitions: early amniocentesis (EA), 11 weeks and 0/7 days to 12 weeks to 6/7 days; early midtrimester amniocentesis (EMA), 13 weeks and 0/7 days to 14 weeks and 6/7 days; and midtrimester amniocentesis (MA), 15 weeks and 0/7 days to 19 weeks and 6/7 days. Outcome measures were obtained by searching the Alberta Congenital Anomalies Surveillance System (ACASS) database for children born with foot anomalies represented by International Classification of Diseases version 9 (ICD-9) codes 754.5, 754.6 and 754.7. RESULTS: Incidences of congenital foot anomalies were: EA 11/980 (1.1%), EMA 11/2515 (0.4%), and MA 1/962 (0.1%). There is a significant difference between the EA and EMA cohorts (p=0.019) and between the EA and MA cohorts (p=0.003); however, these data suggest there is no difference between EMA and MA cohorts (p=0.11). CONCLUSIONS: Our incidence of congenital foot anomalies of 1.1% for women who underwent EA is similar to previously reported data, which further validates this association; however, our data also suggest that the foot anomaly risk may be limited to amniocenteses performed before the 13th week of gestation.

A longitudinal model of intake symptomatology, AA participation and outcome: retrospective study of the project MATCH outpatient and aftercare samples.

OBJECTIVE: The present study used data gathered in Project MATCH to longitudinally assess intake symptomatology, Alcoholics Anonymous (AA) participation, and outcome. Three primary constructs were considered: intake symptomatology, engagement in prescribed AA-related activities and functioning after engagement in AA-related behaviors. METHOD: The participants were 480 outpatient and 434 aftercare clients who participated in Project MATCH. RESULTS: Similar findings were found for each sample. Intake symptomatology positively predicted AA participation during the first 6 months following treatment. Although network support for drinking was negatively related to AA participation, such support did not mediate the relationship between intake symptomatology and subsequent AA participation. AA participation, in turn. positively predicted frequency of abstinent days in Months 7-12 posttreatment. This latter relationship was mediated by perceived self-efficacy to avoid drinking (Month 6). AA participation was positively related to self-efficacy to avoid drinking, which, in turn, predicted more days abstinent. One difference between the outpatient and aftercare samples emerged, involving the latent construct intake symptomatology. Intake symptomatology among outpatients was not predictive of percentage of abstinent days (Months 7-12), whereas intake symptomatology was negatively predictive of percentage of abstinent days in the aftercare sample. CONCLUSIONS: Intake symptomatology positively predicted participation in AA, which predicted subsequent abstinent days. The positive relationship between AA participation and self-efficacy to avoid drinking may explain in part why AA engagement predicts subsequent increases in abstinence.

Alcohol treatment, changes in coping skills, self-efficacy, and levels of alcohol use and related problems 1 year following treatment initiation.

The relationships among alcohol treatment, coping skills, and self-efficacy in predicting alcohol use and related consequences following treatment initiation were investigated. The participants were 77 men and 65 women who were entering either inpatient or outpatient alcohol treatment. The analyses confirmed predictions that treatment, coping skills, and self-efficacy each contributed significantly to the prediction of 12-month alcohol consumption beyond the variance accounted for by participant control variables. Only self-efficacy explained significant additional variance in the consequences outcome. Mediation analyses of the alcohol consumption variables suggested that treatment effects were not mediated by either coping skills or self-efficacy and that the effects of coping skills were not mediated by self-efficacy. The findings are interpreted as providing partial support for social learning theory approaches. Suggestions for future research are discussed.

Treatment settings for persons with alcoholism: evidence for matching clients to inpatient versus outpatient care.

This study compared inpatient, intensive outpatient, and standard outpatient treatment settings for persons with alcoholism and tested a priori hypotheses about the interaction of setting with client alcohol involvement and social network support for drinking. Participants (N = 192) were assigned randomly in cohorts to 1 of the 3 settings. The settings did not differ in posttreatment primary drinking outcomes, although inpatients had significantly fewer jail and residential treatment days combined than outpatients. Clients high in alcohol involvement benefited more from inpatient than outpatient care; the opposite was true at low alcohol involvement levels. Network drinking support did not moderate setting effects. Clients low in cognitive functioning also appeared to benefit more from inpatient than outpatient care. Improved outcomes might be achieved by matching degree of alcohol involvement and cognitive functioning to level of care.

Alcoholics Anonymous and the use of medications to prevent relapse: an anonymous survey of member attitudes.

OBJECTIVE: The purpose of this study was to systematically assess the attitudes of Alcoholics Anonymous (AA) members toward the newer medications used to prevent relapse (e.g., naltrexone) and to assess their experiences with medication use, of any type, in AA. METHOD: Using media solicitations and snowball sampling techniques, 277 AA members were surveyed anonymously about their attitudes toward use of medication for preventing relapse and their experiences with medication use of any type in AA. RESULTS: Over half the sample believed the use of relapse-preventing medication either was a good idea or might be a good idea. Only 17% believed an individual should not take it and only 12% would tell another member to stop taking it. Members attending relatively more meetings in the past 3 months had less favorable attitudes toward the medication. Almost a third (29%) reported personally experiencing some pressure to stop a medication (of any type). However, 69% of these continued taking the medication. CONCLUSIONS: The study did not find strong, widespread negative attitudes toward medication for preventing relapse among AA members. Nevertheless, some discouragement of medication use does occur in AA. Though most AA members apparently resist pressure to stop a medication, when medication is prescribed a need exists to integrate it within the philosophy of 12-step treatment programs.

Predicting the therapeutic alliance in alcoholism treatment.

OBJECTIVE: Prediction of the therapeutic alliance in alcoholism treatment (as rated by the client and by the therapist) was examined in light of a range of potentially relevant factors, including client demographics, drinking history, current drinking, current psychosocial functioning and therapist demographics. METHOD: The data were gathered in Project MATCH. The present analyses were based on data from 707 outpatients and 480 aftercare clients assigned to one of the three Project MATCH treatments. Potential predictor variables were evaluated by first examining bivariate linear relationships between the variables and ratings of the alliance, and then entering blocks of these predictors into multiple linear regression equations with alliance ratings as the dependent variables. All analysis incorporated adjustments for the nonindependence of ratings pertaining to clients seen by the same therapist. RESULTS: In simple regressions evaluating bivariate relationships, outpatients' ratings of the alliance were positively predicted by client age, motivational readiness to change, socialization, level of perceived social support and therapist age, and were negatively predicted by client educational level, level of depression, and meaning seeking. Therapist ratings in the outpatient sample were positively predicted by the client being female and by level of overall alcohol involvement, severity of alcohol dependence, negative consequences of alcohol use, and readiness to change. Among aftercare clients, ratings of the alliance were positively predicted by readiness to change, socialization and social support, and were negatively predicted by level of depression. Therapist ratings of the alliance in the aftercare sample were positively predicted by the client being female and therapist educational level, and were negatively predicted by pretreatment drinks per drinking day. Of the variables having significant bivariate relationships with alliance scores, only a few were identified as significant predictors in multiple regression equations. Among outpatients, client age and motivational readiness to change remained positive predictors and client education a negative predictor of client ratings of the alliance, while client gender remained a significant predictor of therapist ratings. Among aftercare clients, readiness to change and level of depression remained significant predictors of client ratings, while none of the variables remained a significant predictor of therapist ratings. CONCLUSIONS: While the data indicate that several client variables predict the nature of both the client's and therapist's perception of the therapeutic alliance, the significant relationships are of modest magnitude, and few variables remain predictive after controlling for causally prior variables. The strongest relationship identified in both the outpatient and aftercare samples is that between clients' motivational readiness to change and their ratings of the alliance.

Telescoping of landmark events associated with drinking: a gender comparison.

OBJECTIVE: The literature suggests that women exhibit "telescoped" development of (i.e., faster progression to) alcoholism, with fewer years drinking than men. The purpose of this study was to use data gathered in the course of a large clinical trial to further examine this issue. METHOD: Subjects in this retrospective study were from a pool of 1,307 men and 419 women enrolled in Project MATCH, a multisite alcohol treatment matching study. MATCH subjects were recruited from both outpatient and aftercare settings over a 2-year period. Age-of-onset for landmark events in the development of alcoholism were determined from self-report and clinical interviews given at baseline entry into the study. Gender differences in age-of-onset variables were assessed within both outpatient and aftercare settings. Gender differences in progression times between successive landmarks were also examined. Differences were tested with both multivariate and univariate ANOVA techniques. RESULTS: Women generally began getting drunk regularly at a later average age than men (26.6 versus 22.7 years, p< or =.001), began experiencing their first drinking problems at a later average age than men (27.5 versus 25.0 years, p< or =.001) and exhibited loss of control over their drinking at a later average age than men (29.8 versus 27.2 years, p< or =.001). However, these gender differences were most pronounced for older individuals and attenuated for younger subjects. Women also progressed faster than men, on average, between first getting drunk regularly and first encountering drinking problems (0.9 versus 2.3 years, p< or =.001) and between first loss of drinking control and onset of worst drinking problems (5.5 versus 7.8 years, p< or =.001). Women also exhibited shorter average progression times between first getting drunk regularly and first seeking treatment (11.6 versus 15.8 years, p< or =.001), although this effect was negligible for younger subjects. CONCLUSIONS: Telescoping is a relatively robust phenomenon in treatment-seeking alcoholics and indicates that women are more likely to progress faster through the landmark events in the development of alcoholism than are men.

Strategies for preparing clients for treatment. A review.

Substantial numbers of mental health clients do not return following their initial therapy visits or drop out of treatment prematurely. Two general classes of strategies designed to reduce premature attrition and enhance treatment participation are reviewed. Research on psychotherapy preparatory techniques (role induction, vicarious therapy pretraining, and experiential pretraining) indicates that these educational techniques are effective in reducing early treatment attrition and may be especially effective with populations at high risk for dropout (e.g., lower socioeconomic groups, chronically mentally ill clients, and institutionalized juvenile delinquents). Motivational interviewing, a technique originally developed for clients with alcohol problems, is designed to reduce client ambivalence toward therapy and change and enhance commitment to and motivation for treatment. Research in the alcohol field suggests that a session of pretreatment motivational interviewing enhances treatment outcome. Both motivational interviewing and psychotherapy preparatory techniques are relatively brief and easy to incorporate into existing mental health care.

Treating problem drinking.

Recent data suggest that most people experiencing alcohol problems have problems of mild to moderate severity. Relative to alcoholics, these drinkers have a shorter problem-drinking history, greater social and economic stability, and greater personal resources. This article describes a cognitive-behavioral treatment approach designed specifically for problem drinkers with low levels of physical dependence on alcohol who choose to reduce their drinking. After describing various drinking-reduction techniques, the article reviews empirical evidence for drinking-reduction training. The increasing availability of drinking-reduction interventions holds considerable promise for reducing alcohol-related dysfunction among problem drinkers.

Participant selection biases in a randomized clinical trial of alcoholism treatment settings and intensities.

Eligible participants and decliners in a randomized study of inpatient, intense outpatient, and standard outpatient treatments for alcoholics were compared and contrasted on a series of demographic, social stability, psychological, legal, drug use, problem severity, and treatment history variables. Among 302 individuals meeting eligibility requirements, those agreeing to participate, compared with decliners, were more likely to be unemployed, be residentially less stable, have legal problems, use other drugs, have a more severe alcohol problem, have a recent treatment history, and were less likely to have problems with violence. Participants also were more likely to be male and non-white, although gender and racial effects were not significant when other variables were controlled for. The implications of these findings for generalizing the results of inpatient-outpatient studies are discussed, and the need for routine reporting of decliner characteristics in research reports is stressed.

Male and female alcoholics' attributions regarding the onset and termination of relapses and the maintenance of abstinence.

This study was designed to examine male and female alcoholics' attributions of factors associated with the onset and termination of specific relapse events. In addition, data were gathered on factors associated with the achievement and maintenance of abstinent periods. The participants were 77 men and 65 women alcoholics entering alcoholism treatment who were followed for a 12-month period. The two relapse precipitants reported most often by the men were a desire to drink and feeling good. The women most often reported a desire to drink, psychological cravings, letting down one's guard, feeling down, and spouse/partner factors. The women more often reported letting down one's guard and spouse/partner factors as precipitants, relative to the men. Among the factors identified as associated with termination of a relapse, the influences most often endorsed were "just decided to stop" and, among women, feeling bad emotionally. The most frequently identified methods for achieving and maintaining abstinence were avoiding risky people and places, recalling drinking problems (especially among men), treatment, and use of self-help groups.

Internal validity of Project MATCH treatments: discriminability and integrity.

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.

Prevention, not just treatment.

A tragic burden of disease, disability, and death has resulted from smoking. The role of pulmonary rehabilitation is not only in treatment and rehabilitation of lung disease but in the prevention of lung disease. The skills of the pulmonary rehabilitation specialist should be used in the earlier detection and prevention of lung disease through primary and secondary prevention. The spirometer must gain acceptance in the medical community as the early tool to evaluate lung health, not the chest radiograph or the stethoscope. The lung age formula and sputum pap smears are just a few of the evaluation tools used to detect and motivate susceptible individuals. Prevention is the key to enhancing lung health.

Attitudes of young adults to prenatal screening and genetic correction for human attributes and psychiatric conditions.

With recent advances in DNA technology, questions have arisen as to how this technology should be appropriately used. In this article, results obtained from a survey designed to elicit attitudes of college students to prenatal testing and gene therapy for human attributes and psychiatric conditions are reported. The eleven hypothetical disease phenotypes included schizophrenia, alcoholism, tendency toward violent behavior, attention deficit/hyperactivity disorder, depression requiring medical treatment, obesity, involvement in "dangerous" sports activities, homosexuality, borderline normal IQ (80-100), proportional short stature, and inability to detect perfect pitch. Most students supported prenatal genetic testing for psychiatric disorders and behavior that might result in harm to others (i.e., tendency towards violent behavior) and found prenatal genetic testing for human attributes less desirable. However, the lack of unilateral agreement or disagreement toward any one condition or attribute suggests the potential difficulties ahead in the quest for guidelines for the application of new technologies available to manipulate the human genome.