Using Technology to Improve Adherence to HIV Medications in Transitional Age Youth: Research Reviewed, Methods Tried, Lessons Learned.

In transitional age youth living with HIV or AIDS, non-adherence (<80%) to anti-retroviral medication is associated with viral resistance, disease progression, and an increased risk of death. This feasibility study investigated the Maya MedMinder electronic pillbox and cell phone texting with personalized motivational interviewing strategies to improve medication adherence in non-adherent youth. Twenty patients out of 30 identified as non-adherent by the Pediatric HIV team at the Medical University of South Carolina were approached, and 15 were recruited (Ages 12 to 20; 13.3% male, 86.7% female; 100% African-American). Following baseline MedMinder monitoring, subjects were randomized to intervention groups with reminder signals on or off. The time medications were taken was collected by the MedMinder, resulting in adherence scores. All were interviewed for readiness to change utilizing the Motivational Interviewing (MI) Stages of Change scores. Viral load and CD4 labs were scheduled every 6 weeks. Despite monetary incentives and personalized support, recruitment and adherence to the protocol was a challenge. Only 6/15 subjects completed the entire study scheduled for 6-months .Stages of change scores revealed that those that transitioned to making changes had higher CD4 percentages midway through the study. Challenges included missed appointments and labs despite efforts by text and phone to schedule convenient appointment times with participants. Device challenges included the large size of the MedMinder and faulty electronic signaling, especially from rural areas. The methodology was feasible with these patients. This small feasibility study highlights that technological tools to promote adherence and motivational enhancement strategies in teens and young adults who are non-adherent to HIV medication regimens can enhance biomarker outcomes associated with medication adherence.

Phototherapy, photodynamic therapy and photophoresis in the treatment of connective-tissue diseases: a review.

Connective-tissue disorders, which include lupus erythematosus, morphoea/scleroderma and dermatomyositis, are characterized by cutaneous manifestations that are sometimes resistant to conventional therapy. Light treatments, which include phototherapy, photodynamic therapy (PDT) and photopheresis, are routinely utilized in the treatment of dermatological conditions and may provide unique mechanisms of action in the treatment of these connective-tissue disorders. The objective of this study is to conduct a review of the literature that describes the use of phototherapy, PDT and photopheresis in the treatment of lupus erythematosus, morphoea/scleroderma and dermatomyositis. A MEDLINE search was conducted to find articles that discuss treatment of connective-tissue diseases with light therapies and more than 30 publications that discuss light therapy for these diseases were identified. These range in design from case reports to randomized, prospective trials. Study outcomes and details were summarized and presented within each connective-tissue disease by light therapy modality, which includes phototherapy, PDT and photopheresis. Although there is a known association between photosensitivity and connective-tissue diseases, light therapies, when used appropriately, may be legitimate therapeutic options for recalcitrant cutaneous manifestations in lupus erythematosus, morphoea/scleroderma and dermatomyositis.

A fatality due to accidental PineSol ingestion.

The case history and toxicological findings of a fatal PineSol intoxication are presented. An 89-year-old white female with Alzheimer's disease accidentally drank PineSol and was subsequently brought to the hospital where she was pronounced dead on arrival. Significant autopsy findings included acute erosive gastritis. There appeared to be no aspiration of PineSol into the lungs. Isopropanol along with 1-alpha-terpineol are the two major toxic ingredients of PineSol. The toxicological screening and quantitiation of 1-alpha-terpineol in postmortem fluids was performed by gas chromatography-mass spectrometry using a simple one-step extraction. Postmortem blood, urine, and gastric levels of 1-alpha-terpineol were 11.2 mg/L, 5.76 mg/L, and 15.3 g/L, respectively. Postmortem blood, vitreous humor, urine, and gastric acetone concentrations were 25, 31, 33, and 28 mg/dL. Postmortem concentrations of isopropanol were less than 10 mg/dL in the blood, vitreous humor, urine, and gastric contents. The cause of death was ruled acute 1-alpha-terpineol intoxication due to accidental ingestion of PineSol, presumably caused by confusion related to Alzheimer's disease.

Psychological functioning in children and adolescents undergoing radiofrequency catheter ablation.

This study examined 38 patients (age 6-18 years) with recurrent cardiac arrhythmias who underwent radiofrequency catheter ablation of ectopic myocardial foci. Psychological functioning was assessed by the Pediatric Symptom Checklist, Short Mood and Feeling Questionnaire, Revised Children's Manifest Anxiety Scale, and Arrhythmia Anxiety Queries prior to ablation and at 3-month follow-up. The patients resembled a normal population without elevations in anxiety or depression. After ablation, the patients showed reductions in the "fear of their heart problem" and increases in "the things that they enjoy." The patients who underwent a curative ablation had better functioning than those who did not show improvement. Children appear to have the opportunity for an improved quality of life after ablation.

Reactive Attachment Disorder: what we know about the disorder and implications for treatment.

In recent years, there has been an increase in the number of children diagnosed with Reactive Attachment Disorder (RAD). There is considerable disagreement about what this entity actually entails and, in particular, what types of assessments and interventions to use with these children and families. Children with a history of maltreatment (i.e., physical, sexual, emotional abuse, and/or severe neglect) are particularly likely to receive this diagnosis, because the behavior problems often seen in these children are presumed to stem from the maladaptive relationships they have had with abusive caregivers. However, many children are receiving this diagnosis because of behavior problems that clearly extend beyond the DSM-IV criteria for RAD. Perhaps the most concerning consequence of the RAD diagnosis is the emergence of novel treatments that lack a sound theoretical basis or empirical support, and may potentially be traumatizing and dangerous to the child. Thus, the purpose of this article is to review and synthesize what is known about RAD and attachment disorders and to discuss implications for treatment.

A fatality related to the veterinary anesthetic telazol.

A 45-year-old male veterinarian was found dead in bed. Police investigation showed no evidence of trauma or other suspicious circumstances. Autopsy was unremarkable except for cardiomegaly and hepatosplenomegaly. Toxicological analysis revealed the presence of Telazol and ketamine. Telazol is a veterinary anesthetic agent that is composed of equal parts of tiletamine and zolazepam. Tiletamine is a disassociative anesthetic similar to ketamine and phencyclidine, and zolazepam is a diazepine derivative tranquilizer used to minimize the muscle hypertonicity and seizures associated with tiletamine. Quantitation of tiletamine and zolazepam was performed using gas chromatography-mass spectrometry in the selected ion monitoring mode following a solid-phase extraction. Postmortem blood, urine, and liver concentrations of tiletamine were 295 ng/mL, 682 ng/mL, and 196 ng/g, respectively, whereas postmortem concentrations of zolazepam for the same tissues were 1.71 microg/mL, 1.33 microg/mL, and 15.5 microg/g, respectively. Blood and urine ketamine levels were 37 ng/mL and 381 ng/mL, respectively. The cause of death was ruled an acute mixed drug intoxication of tiletamine, zolazepam, and ketamine with the manner of death ruled as unclassified.

Use of the pediatric symptom checklist in the pediatric neurology population.

The purpose of this study was to evaluate the effectiveness of the Pediatric Symptom Checklist (PSC) as a mental health screening instrument in a busy pediatric neurology population in comparison with more lengthy, time-consuming assessment methods. One hundred two children were screened using the PSC. PSC results were compared with scores on the Child Behavior Checklist (CBCL), results from structured interviews, and ratings of adaptive functioning using the Children's Global Assessment Scale (CGAS). Thirty-nine of the patients (38%) scored 63 or above on the CBCL, indicating psychosocial impairment. Using a cutoff score of 22, the PSC correctly identified 35 of these 39 positive cases (sensitivity 89.7) and 48 of the 63 children with CBCL scores below 63 (specificity 76.2). CGAS scores were significantly negatively correlated with PSC scores (r = -0.60, P < 0.05). The PSC correctly identified 85.9% of children who scored 70 or below on the CGAS. Among the 53 children with psychiatric diagnoses on the basis of the interview, 41 scored above the cutoff of 22 on the PSC. Results suggest that the PSC is an efficient and accurate screen for identification of mental health problems in the pediatric neurology population.

Quantitative analysis of p53 protein in non-small cell lung cancer and its prognostic value.

Accumulation of mutant p53 protein occurs frequently in human malignancies, including 40-60% of non-small cell lung carcinomas. The implications of such p53 over-expression, usually assessed by immunohistochemical techniques, for the prognosis of lung cancer patients remain undetermined. In this study, we used a time-resolved immunofluorometric assay to measure p53 protein concentrations in extracts prepared from 86 primary non-small cell lung tumours and examined the associations between p53 protein levels (corrected for total protein) and other clinico-pathologic variables, including post-surgical disease-free and overall survival. Contingency tables analysed by chi2 tests revealed no significant relationships between p53 status, defined by a median cut-off point, and patient gender, age, disease stage, histologic grade and type, lymph node extension, smoking history and administration of adjuvant chemotherapy or radiation. However, multivariate Cox proportional hazard regression analysis demonstrated a dose-response relationship between p53 concentration, expressed as a 4-level, quartile-divided variable, and increased risk of relapse (p = 0.010) and death (p = 0.016). Patients whose tumours contained p53 concentrations exceeding the median value had over 3-fold higher risk of relapse (p = 0.002) and death (p = 0.007) than those whose tumours had lower p53 concentrations. We also provide evidence suggesting that the impact of p53 on survival is greater in patients with squamous cell carcinoma than in those with adenocarcinoma. Although the latter finding needs confirmation, our results suggest that application of an immunoassay of p53 protein on non-small cell lung tumour extracts may identify patients at increased risk of unfavourable outcome.

Children with both developmental and behavioral needs: profile of two clinic populations.

Little has been written about evaluation and intervention services for children with a combination of behavioral and developmental needs. Two multidisciplinary clinic populations were compared, a traditional Developmental Disabilities (DD) clinic and a Behavioral-Developmental Problems (BDP) Clinic that had the additional services of a child psychiatrist. The BDP clinic children had lower IQ's and more severe overall behavioral problems than children in the traditional DD clinic, but differences were not statistically significant. Children with Attention Deficit Hyperactivity Disorder (ADHD) and other psychiatric diagnoses were referred to both clinics at comparable rates. The effort to involve qualified mental health professionals in all aspects of professional training and clinical service for the DD population should be accelerated.

LC/MS with a particle beam interface in forensic toxicology.

Many instruments are used in forensic toxicology to screen biologic samples for drugs and other compounds. Many of these screening instruments (and others) are used to confirm positive screening tests. The focus of this article is the use of a high pressure liquid chromatograph/mass spectrometer (HPLC/MS) for screening forensic postmortem and human performance DWI cases. This screening procedure involves an HPLC with a particle beam interfaced to a mass spectrometer detector and a photodiode array detector. Drugs such as the antidepressants, drugs of abuse, over-the-counter cold and pain preparations, anticonvulsants, benzodiazepines, and some medications that are not available in the United States are selected at therapeutic and subtherapeutic levels. Limits of detection and extraction efficiencies are presented for many compounds. Several cases are discussed showing different drug combinations.

Bulimia and dextromethorphan abuse. A case study.

The comorbidity of bulimia and substance abuse is significant. The substance that is abused may vary and the abuse potential for nonillicit substances may be overlooked. This paper presents the first case reported of dextromethorphan abuse and bulimia. It demonstrates the complexity of assessment and treatment of bulimia and substance abuse of over-the-counter medications.

Impact of psychologic functioning, medical severity, and family functioning in pediatric heart transplantation.

BACKGROUND AND METHODS: This study examined (1) the psychologic functioning of children and adolescents before and after heart transplantation and (2) whether pretransplantation psychologic functioning, posttransplantation medical severity, and family functioning were related to the patients' posttransplantation psychologic functioning. The subjects were 23 patients, ages 3 to 20 years, who underwent heart transplant and survived at least 1 year after their transplantation. Psychologic functioning was assessed by the Children's Global Assessment Scale before and after heart transplantation. Medical severity was assessed by number of outpatient visits, hospitalizations, biopsies, and the Side Effect Severity Scale. Family functioning was rated on the Global Assessment of Family Relational Functioning Scale. RESULTS: The majority of the patients (78.3%) had good psychologic functioning after their heart transplantation. Patients with psychologic difficulties before and after transplantation had more hospitalizations after transplantation. CONCLUSIONS: Pretransplantation emotional functioning and family functioning were more correlated with posttransplantation psychologic functioning than medical side effect severity.

Normally saprobic cryptococci isolated from Cryptococcus neoformans infections.

We report two cases in which Cryptococcus laurentii was isolated from surgically resected pulmonary lesions but the cryptococcal cells is tissue reacted positively with a specific fluorescent antibody (FA) conjugate for Cryptococcus neoformans. Both patients had no apparent host defense defects. In both cases, multiple cryptococcal isolates were obtained from tissue, and yeastlike cells consistent with C. neoformans were seen in direct histology. The isolates were identified by assimilation patterns and standard procedures including phenoloxidase reactions. Since C. laurentii was consistently isolated by using stringent procedures, it was considered unlikely that the fungus represented surgical or laboratory contamination. Its presence may be the result of dual infection not detected by FA, but other possible explanations exist. The results show the value of the FA test in diagnostic mycology and call into question previous reports of cryptococci other than C. neoformans as agents of infection.

Closure of chronic postpneumonectomy bronchopleural fistula using the transsternal transpericardial approach.

Thirteen patients with postpneumonectomy bronchopleural fistula occurring 4 months to 10 years after the initial operation have been treated with a transsternal transpericardial approach after the associated empyema had been treated by either tube thoracostomy or open-window thoracostomy. In 10 patients, there were contraindications to using an ipsilateral transthoracic approach. In 10 of the 13 patients, the procedure was successful. Three fistulas recurred; two were quite small, one of them closing spontaneously within 6 months. There were no deaths or clinically significant morbidity related to the transsternal approach. We have found this technique to be most applicable in those patients in whom other procedures have failed to resolve the problem. The technique is relatively simple and safe.

Percutaneous endoscopic gastrostomy by the "pull" and "introducer" methods.

After 28 patients, studied prospectively, underwent percutaneous endoscopic gastrostomy (PEG) by the Ponsky "pull" technique, another 28 patients underwent PEG by the Russell "introducer" method. These two groups were compared retrospectively with 28 patients who had previously undergone Stamm gastrostomy as an independent operation performed by the same group of surgeons. All procedures were done within a 5-year period. The major indication for gastrostomy was the inability to swallow due to neurologic diseases; a similar number of patients in each group also had pharyngeal blockage, cachexia, respiratory failure and inhalation burns. Percutaneous endoscopic gastrostomy could be done most appropriately under local anesthesia, the "introducer" method requiring less time than the "pull" method, which in turn required less time than the Stamm gastrostomy. Feeding was generally instituted successfully 24 hours after PEG compared with 3 days after Stamm gastrostomy. "Introducer" PEG was not associated with peristomal infection, and the authors postulate that the peristomal infections in the "pull" PEG group were due to oropharyngeal bacteria brought through the abdominal wall by that technique.

Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula.

Postpneumonectomy empyema, with or without bronchopleural fistula, remains an infrequent but serious complication of pulmonary resection. We reviewed our experience with the Clagett procedure in 31 patients with postpneumonectomy empyema. Seven had empyema alone and 24 had empyema with bronchopleural fistula. Ten patients died of metastatic disease without attempted closure of the thoracostomy window. In eight patients the total Clagett procedure was completed; window closure was permanent in two patients, but the remaining six had recurrence of empyema (four of whom had persistent occult fistulas). In eight further patients, persistent infection prevented attempted closure of the window. Five patients refused further surgical procedures. In only two of 31 patients were we able to achieve permanent closure of the thoracostomy window. Based on this experience, we conclude that open window thoracostomy provides adequate drainage and an excellent interim or permanent treatment of the infected pneumonectomy space. However, the presence of persistent bronchopleural fistula prevents successful completion of the total Clagett procedure. In our series, there were no deaths related to empyema or the surgical procedures performed for it.

A modified Sugiura procedure.

The Sugiura procedure for esophageal varices combines splenectomy with esophagogastric devascularization, which destroys the intraesophageal portacaval shunt but preserves periesophageal portacaval shunts. We have modified the total vagotomy and pyloroplasty and sutured esophageal anastomosis of the original operation. A single left thoracoabdominal incision is used. Esophagogastric devascularization is performed without dividing the main vagus trunks; only a proximal gastric vagotomy is done, thereby avoiding a pyloroplasty. The esophageal transection and reanastomosis are performed with the circular End-to-End Anastomosis stapler and protected with a loose-fundal wrap. Fifteen of 20 patients have had good to excellent results, with rapid recovery and no recurrent esophagogastric bleeding or any hepatic encephalopathy in follow-up of two months to two years. Four patients, who were bleeding massively at the time of operation and who were in Child's class C with gross ascites, muscle wasting, ad coagulopathy, died in the postoperative period. Conceptually, the operation is original and exciting because it preserves hepatic blood flow and the beneficial periesophageal shunt, while destroying the harmful intraesophageal shunt. Our early experience encourages us to continue using this operation, except in those patients who bleed massively and are in Child's C, end-stage, class.