Utility of proactive infliximab levels in paediatric Crohn's disease.

OBJECTIVE: Infliximab (IFX) has an established role in Crohn's disease (CD), with serum trough levels of IFX (TLI) increasingly used to optimise dosing. We report the utility of routine, proactive TLI in children on combination therapy with immunosuppression (IS) from a single paediatric centre. METHODS: This is a retrospective chart review of all children with CD receiving IFX therapy conducted betweenJanuary 2014-May 2017. Clinical phenotype, duration of therapy, TLI (µg/mL), drug antibodies, type of IS, biomarkers and changes in management were recorded. RESULTS: 60 children (8-17 years; median 14.1 years) had 206 TLIs recorded. 56/60 (93%) were on IS, with 5/60 (8%) developing antidrug antibodies (ADAs). 63/206 TLIs were recorded duringan episode of relapse (median 3.0 µg/mL) vs 143/206 TLIs recorded in remission (median 5.2 µg/mL). For children with TLI <3 µg/mL, 31/63 (49%) were in relapse vs 30/143 (21%) in remission. For children with TLI >7 µg/mL, 7/63 (11%) were in relapse vs 46/143 (32%) in remission. Change in management resulted from 43/206 (21%) TLIs in 31/60 (52%) children: 21 dose escalations, 12 de-escalations and 10 changed to adalimumab. Of 31 postinduction TLIs, 15/17 (88%) children with TLI >7 µg/mL achieved clinical and biochemical remission for the duration of therapy (median 14 months), while 4/5 (80%) children with TLI <3 µg/mL required early dose escalation. Combination therapy with thiopurines (TP) (median TLI 4.9 µg/mL) versus methotrexate (MTX) (median TLI 5.2 µg/mL) achieved comparable levels with no difference in relapse frequency. CONCLUSIONS: Routine, proactive TLIs guide optimal management in children with CD. Postinduction and during maintenance, levels <3 µg/mL were associated with relapse and levels >7 µg/mL with sustained remission. Combination IS with TP and MTX appears to offer comparable TLI and ADA rates.

Validity of behavioral measures as proxies for HIV-related outcomes.

Over the last 30 years, expectations for the quality, validity, and objectivity of the outcome measures used to assess the impact of behavior change interventions related to HIV have steadily increased. At this point (mid-2014 at this writing), biologic evidence or biomarkers of the incidence of HIV and other sexually transmitted infections in a target population is clearly preferable to self-reports of behavior. This kind of evidence is, however, much more expensive to collect than participants' reports of behavior change (eg, increased condom use, reduced substance use or abstinence from substance use, and high levels of medication adherence). In addition, although potentially less subject to reporting bias, biomarkers and biologic outcomes have their own flaws. In this article, we review the literature on the validity of self-reports of outcomes most relevant to HIV behavior change interventions, sexual behavior (ever having had sex and condom use), substance use, and medication adherence. We note the extent to which they may be adequate outcome measures without biologic data, and the conditions under which they may be most likely to be sufficient. We also argue, like many others, that where possible, both self-report and biologic measures should be collected.

Drug treatment services for adult offenders: the state of the state.

We conducted a national survey of prisons, jails, and community correctional agencies to estimate the prevalence of entry into and accessibility of correctional programs and drug treatment services for adult offenders. Substance abuse education and awareness is the most prevalent form of service provided, being offered in 74% of prisons, 61% of jails, and 53% of community correctional agencies; at the same time, remedial education is the most frequently available correctional program in prisons (89%) and jails (59.5%), whereas sex offender therapy (57.2%) and intensive supervision (41.9%) dominate in community correctional programs. Most substance abuse services provided to offenders are offered through correctional programs such as intensive supervision, day reporting, vocational education, and work release, among others. Although agencies report a high frequency of providing substance abuse services, the prevalence rates are misleading because less than a quarter of the offenders in prisons and jails and less than 10% of those in community correctional agencies have daily access to these services through correctional agencies; in addition, these are predominantly drug treatment services that offer few clinical services. Given that drug-involved offenders are likely to have dependence rates that are four times greater than those among the general public, the drug treatment services and correctional programs available to offenders do not appear to be appropriate for the needs of this population. The National Criminal Justice Treatment Practices survey provides a better understanding of the distribution of services and programs across prisons, jails, and community correctional agencies and allows researchers and policymakers to understand some of the gaps in services and programs that may negatively affect recidivism reduction efforts.

How much for a dime bag? An exploration of youth drug markets.

Relatively little is known about how youth obtain marijuana and other drugs. The Drugs, Alcohol and Violence International (DAVI) study explored youthful drug markets among samples of school students, detained youth, and school dropouts (ages 14-17 years) in the greater metropolitan areas of Philadelphia, Toronto, Montreal, and Amsterdam. Students frequently reported sharing drugs, either getting them from others or giving them to others for free. Sharing was less common among the more drug-involved detainees and dropouts. Marijuana was typically obtained either outdoors or in a house or apartment. Few youth reported getting marijuana at school. In Amsterdam, where marijuana can be purchased in small quantities in coffeeshops, this was the most common place to get marijuana, even though 18 is the legal age for purchase. Alcohol was also most likely to be obtained in stores or restaurants across all the sites, even though none were of legal age except those in Amsterdam age 16 or older. Youth most often reported purchasing marijuana in nickel, dime or other small bags, which are not standardized units. The exception again was Amsterdam, where youth most often reported quantities in grams or joints, which is how it is sold in coffeeshops. The lack of standardization of units makes economic cost estimates suspect. Even standardized units such as alcohol present problems since youth report a wide range of 'typical purchases.' Survey data can, however, more aptly describe drug market characteristics such as general location of purchase, and relationship with the seller.

Girls and weapons: an international study of the perpetration of violence.

The purpose of this study was to describe delinquent girls' weapons preferences where and how often they carried weapons and to identify the most important factors that explained four different weapon-related violent outcomes. A large, high-risk sample of female adolescents consisting of 510 girls aged 14-17 in four cities were interviewed using the same questionnaire and methods. Tabular and logistic regression analyses were applied. Knives emerged as the most frequently reported weapon in all cities. Rates of both lifetime victimization and perpetration of violence with weapons were high in all sites. Starting to carry a weapon as a result of violence was reported by 40% of the girls in Toronto, 28% in Philadelphia, 25% in Amsterdam, and 16% in Montreal. The major predictors of weapon perpetrated violent behaviours included ethnic origin, early onset of delinquent activities, participation in delinquent acts in the past 12 months, gang fighting and carrying a weapon as a result of violence. Site, age and heavy alcohol consumption had a minor impact, and drug use, drug selling, and neighborhood features, none. Despite numerous differences in weapons' prevalence across cities, the logistic regression found that site was only significant in use of an object (Toronto) and not significant in threatening or hurting someone with either a knife or a gun or actually hurting others with a weapon. These findings suggest commonality in serious female violence that extends beyond borders and cultures.

Introduction: Progress and issues in drug treatment courts.

The first drug treatment court began in Miami, Florida in 1989, in direct response to the backlog of court cases for drug possession and trafficking. By mid-2001, there were 700 operational drug treatment courts and 400 more in the planning stages in the United States. In addition to providing an overview of the growth and development of drug treatment courts in the United States, this special issue examines their development in Australia, Canada, and the United Kingdom. The primary focus is the evaluation research conducted to date, which identifies some of the critical unresolved issues facing drug treatment courts.