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Long-term mental health sequelae of the 1986 Chernobyl disaster have been documented for exposed populations who remained in the former Soviet Union (FSU) (Havenaar et al., 1997), and in a cohort migrated to Israel (Cwikel et al., 1997). This paper reports on Chernobyl disaster sequelae in émigrés (n = 321) to the United States. Demographic characteristics, migration factors, and self-reported physical health were considered. Both geographical proximity to the 1986 disaster, and perception of radiation risk stood as long-term indicators of current psychological distress. Proximity was related to poor self-perceived physical health, as well as current symptoms of depression (p<.05), anxiety (p<.01), and Chernobyl-related trauma distress (p<.001) on standardized measures. Environmental contamination as a reason for migration was also associated with greater mental health symptomatology. [ABSTRACT FROM AUTHOR]

Interventions targeting high-risk drug users have found reductions in HIV risk behaviors over time. It is important to determine whether these changes occur among both HIV+ and HIV- drug users. A total of 225 drug injectors (31% HIV+) and 316 crack users (15% HIV+) were administered a baseline interview, received HIV testing, received test results, and participated in a 6-month follow-up interview. Both HIV+ and HIV- subjects significantly reduced risk behaviors over time, with greater reduction in some behaviors (e.g., percent of injectors sharing drug injection paraphernalia, p < .05) by HIV+ subjects. This finding supports the utility of HIV testing for high-risk drug users. Further research is needed to enhance understanding of risk behaviors and risk reduction among seropositives. [ABSTRACT FROM AUTHOR]

Doxofylline, an oral methylxanthine with bronchodilator and anti-inflammatory activities, offers a promising alternative to theophylline due to its superior efficacy/safety profile. No long-term studies on the efficacy and safety of doxofylline are currently available in asthma. The aim of the Long-term clinical trial on the Efficacy and Safety profile of Doxofylline in Asthma (LESDA) study was to investigate the safety and efficacy profile of doxofylline administered for one year in asthmatic patients. LESDA was a multicenter, open-label, Phase III, clinical trial in which adult asthmatic patients received the same treatment (oral doxofylline 400 mg t.i.d.) for one year. Efficacy was assessed through periodic pulmonary function tests and by having the subjects keep monthly records of asthma events rates and use of salbutamol as rescue medication. The rate of adverse events (AEs) was recorded during the study. Three-hundred nine patients were screened and allocated in the study. Doxofylline significantly improved the change from baseline in forced expiratory volume in 1 s (FEV 1 ) (+16.90 ± 1.81%, P < 0.001 vs. baseline). Doxofylline also significantly improved the rate of asthma events (events/day: -0.57 ± 0.18, P < 0.05 vs. baseline) and the use of salbutamol as rescue medication (puffs/day: -1.48 ± 0.25, P < 0.01 vs. baseline). The most common AEs were nausea (14.56%), headache (14.24%), insomnia (10.68%), and dyspepsia (10.03%). There were neither serious AEs nor deaths during or shortly after the study. Concluding, doxofylline is effective and well tolerated when administered chronically in asthmatic patients., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This pooled analysis of double-blind, randomized, placebo-controlled trials aimed to investigate the impact of DOxofylline compaRed tO THEOphylline (DOROTHEO 1 and DOROTHEO 2 studies) on functional and clinical outcomes in asthma. Asthmatic patients ≥16 years of age with forced expiratory volume in 1 s (FEV 1 ) ≥50% and <80% and with ≥15% post-bronchodilator increase in FEV 1 were randomized in a 1:1:1:1 ratio in DOROTHEO 1 to receive doxofylline 200 mg, doxofylline 400 mg, theophylline 250 mg, or placebo; in DOROTHEO 2 patients were randomized in a 1:1:1 ratio to receive doxofylline 400 mg, theophylline 250 mg, or placebo. All double-blind treatments were taken orally with immediate release formulations and three times daily. Data evaluating the effect of doxofylline 400 mg, theophylline 250 mg and placebo on FEV 1 , asthma events rate, use of salbutamol as rescue medication and adverse events (AEs) were pooled from both studies. The pooled-analysis of 483 patients demonstrated that both doxofylline 400 mg and theophylline 250 mg significantly increased FEV 1 , reduced the rate of asthma events and use of salbutamol to relieve asthma symptoms compared to placebo (p < 0.01). No significant differences were detected between doxofylline 400 mg and theophylline 250 mg. Doxofylline 400 mg did not significantly (p > 0.05) increase the risk of AEs compared to placebo, conversely in patients treated with theophylline 250 mg the risk of AEs was significantly (p < 0.05) greater than in those that received placebo. We conclude that doxofylline seems to offer a promising alternative to theophylline with a superior efficacy/safety profile in the management of patients with asthma., (Copyright © 2018. Published by Elsevier Ltd.)

Veterans with posttraumatic stress disorder (PTSD) and their families require resources to cope with postdeployment readjustment. Responding to this need, the current study examined a brief Internet-based intervention that provided Veterans' families with psychoeducation on postdeployment readjustment. Participants were 103 dyads of Veterans with probable PTSD and a designated family member/partner. Dyads were randomized to an intervention group, in which the family member completed the intervention, or to a control group with no intervention. Each member of the dyad completed surveys at baseline and 2 mo follow-up. Family member surveys focused on perceived empowerment, efficacy to provide support, and communication (perceived criticism and reactivity to criticism). Veteran surveys assessed perceived family support and communication. Results showed that Veterans in the intervention group reported decreases in reactivity to criticism but also decreased perceived family support. No significant differences were observed in outcomes reported by family members. This preliminary study provides an early understanding of this novel outreach program, as well as the challenges inherent with a very brief intervention. Future research can build on the current study by more closely evaluating the communication changes that occur with this form of intervention and whether greater intervention intensity is needed., Clinical Trial Registration: Clinical Trials Identifier: NCT01554839.

Aims: Individual interviews were conducted and analyzed to learn about the engagement of suicidal veterans in safety planning., Method: Twenty suicidal veterans who had recently constructed safety plans were recruited at two VA hospitals. In semistructured interviews, they discussed how they felt about constructing and using the plan and suggested changes in plan content and format that might increase engagement., Results: The veterans' experiences varied widely, from reviewing plans often and noting symptom improvement to not using them at all and doubting that they would think of doing so when deeply depressed., Conclusion: The veterans suggested ways to enrich safety planning encounters and identified barriers to plan use. Their ideas were specific and practical. Safety planning was most meaningful and helpful to them when they experienced the clinician as a partner in exploring their concerns (e.g., fear of discussing and attending to warning signs) and collaborating with them to devise solutions.

Deaf adolescents who use American Sign Language (ASL) as their main communication mode are, like their hearing age peers, at risk for acquiring HIV. Many sources of HIV information (radio and television) are not accessible to these adolescents. Little is known about HIV knowledge base and risk behaviors of this group. The objective of this study was to develop and administer, on laptop computer, an HIV knowledge and risk survey in ASL. Findings among 700 deaf adolescent participants attending high schools for the deaf throughout the United States showed that, on average, students knew correct answers to approximately half (x = 7.2) of 14 knowledge items (median: 7.0; range: 0-14; sd = 3.8) on a highly reliable knowledge scale (α = .83). Knowledge score was found in multivariable analysis to be strongly related to receiving HIV information in school. This population is clearly in need of linguistically and culturally accessible HIV prevention education delivered in school.

Gender differences were examined in health status and HIV care among HIV-infected minority drug users. More women than men reported having HIV-related symptoms and other health conditions, such as asthma and allergies. Hepatitis B or C was more often reported by men. As compared to men, women delayed HIV care and fewer attended HIV support groups. Delayed entry into HIV treatment was also significantly related to being Hispanic and being diagnosed with HIV in the pre-HAART era. No significant gender difference was found in current use of HIV medications. Use of HIV medications was significantly related to being married, no history of childhood sexual abuse, enrollment in an HIV clinic and attending HIV support groups. The findings demonstrate the importance of family and social support for HIV-positive drug users and also suggest a need for special attention to those who have childhood sexual abuse experience.

Objective: Limited information exists on features of pediatric Selective IgM immunodeficiency (SIgMID). Previously published pediatric cases and 2 new cases are reviewed., Methods: English literature from PubMed and references from relevant articles were reviewed. Previously reported cases and 2 new cases from an allergy/immunology practice were analyzed., Results: Forty-nine reported cases of SIgMID presented with respiratory infections (77.6%), gastrointestinal disease (16.3%), skin disease (12.2%), and meningitis (8.2%). Mean serum IgM level was 16.5+/-13.8 mg/dL. Two patients were identified with SIgMID among 6300 active pediatric patients (0.03%) presenting with asthma, vasomotor rhinitis, and recurrent respiratory infections. In the 51 cases reported, none developed lymphoproliferative disease nor evolved into panhypogammaglobulinemia; four fatalities were reported., Conclusions: The prevalence of SIgMID in our pediatric population was 0.03%. In general, respiratory infections are the common comorbid conditions. Death and autoimmune disease are uncommon complications of pediatric SIgMID.

Objective: To review and compare previously reported cases of selective IgM immunodeficiency (SIgMID) with the largest adult cohort obtained from a retrospective analysis of an allergy and immunology practice., Data Sources: Publications were selected from the English-only PubMed database (1966-2005) using the following keywords: IgM immunodeficiency alone and in combination with celiac disease, autoimmune disease, malignancy, and infection. Bibliographic references of relevant articles were used., Study Selection: Reported adult SIgMID cases were reviewed and included in a comparative database against our cohort., Results: Previously described patients with SIgMID include 155 adults and 157 patients of unspecified age. Thirty-six adult patients were identified with SIgMID from a database of 13,700 active adult patients (0.26%, 1:385). The mean +/- SD serum IgM level was 29.74 +/- 8.68 mg/dL (1 SD). The mean +/- SD age at the time of diagnosis of SIgMID was 55 +/- 13.5 years. Frequency of presenting symptoms included the following: recurrent upper respiratory tract infections, 77%; asthma, 47%; allergic rhinitis, 36%; vasomotor rhinitis, 19%; angioedema, 14%; and anaphylaxis, 11%. Serologically, 13% of patients had positive antinuclear antibodies (ANAs), 5% had serologic evidence of celiac disease, and nearly all had non-AB blood type. Patients also had low levels of IgM isohemagglutinins. No patients developed lymphoproliferative disease or panhypogammaglobulinemia, and none died of life-threatening infections, malignancy, or fulminant autoimmune-mediated diseases during a mean follow-up period of 3.7 years., Conclusions: The prevalence of SIgMID in our adult population was 0.26% and may be more common than previously thought. Non-life-threatening respiratory disorders were common comorbid conditions.

This study compared health care utilization and HIV-related risk behaviors between HIV-infected African American (n=123) and Hispanic (n=97) drug users recruited in New York City. African Americans were more likely to use crack, while Hispanics were more likely to use heroin and speedball. African Americans were more likely than Hispanics to report having traded sex for drugs or money. The two groups did not significantly differ in HIV care utilization (e.g., taking HIV medications). In multiple logistic regression analyses, for African Americans, taking HIV medications was significantly related to enrollment in HIV clinics and non-use of crack, while for Hispanics, being married and attending HIV support groups were significant factors. Drug treatment enrollment was significantly related to non-use of crack and injection drug use among African Americans, and a trend (p=.07) was found between injection drug use and drug treatment enrollment among Hispanics. The findings indicate the continuing need for harm reduction programs for HIV positive drug using populations. Programs for these populations should also take into account the different risk behaviors among different racial/ethnic groups, in order to tailor culturally sensitive programs for HIV care and intervention.

It is important to identify social conditions, program factors, and client characteristics that predict retention because time in substance abuse treatment is associated with improved health, mood, and social functioning. Treatment dropouts also are at high risk for serious harms, including relapse. Most opioid-dependent persons require long-term stabilization in methadone maintenance treatment (MMT) to normalize brain function and control withdrawal symptoms. The purpose of this study was to determine whether a client characteristic, namely, attitude toward methadone, was related to retention. Analysis of 14 opinion statements about methadone identified a reliable five-item scale with factorial validity. This scale (Opinions About Methadone; OAM-5) also predicted retention in MMT. Of 338 clients followed for one year after MMT enrollment, 48% dropped out of treatment; those who were more likely to remain had more favorable opinions. A supplementary qualitative study with MMT counselors demonstrated face validity for the OAM-5; counselors found the items easy to interpret and relevant to client attitudes towards MMT. The findings suggest that it would be worthwhile for MMT staff to assess client attitudes at intake, using the OAM-5. This would help them to identify and intervene promptly with those in greatest need of support for remaining in treatment.

Objective: The purpose of this study was to examine the relationships between childhood abuse/neglect experiences (sexual abuse, physical abuse, emotional abuse, and child neglect) and adult life functioning among Methadone Maintenance Treatment Program (MMTP) drop-outs., Method: 432 subjects who dropped out of MMTP were recruited in New York City in 1997-1999. Adult life functioning was measured by HIV drug and sex risk behaviors, Addiction Severity Index (ASI) composite scores, and depression. The chi(2) tests, t tests, correlation, and multiple logistic regressions were performed to examine the relationships between abuse experiences and adult life functioning., Results: The prevalence of child abuse/neglect history was high among MMTP drop-outs: sexual abuse-36%; physical abuse-60%; emotional abuse-57%; child physical neglect-66%; all four experiences-25%. As assessed via ASI composite scores, those who had been abused in childhood had significantly more medical, legal, relationship, and psychological problems than those who had not. Overall, several significant associations were found between the abuse experiences and HIV risk behaviors. Those who had experienced child neglect were more likely to be HIV positive. In multivariate analyses, childhood physical abuse was a significant predictor of having multiple sex partners while depression was significantly related to injection drug use in adulthood (p<.05). There were trends for the relationships between childhood sexual abuse and HIV sex risk behavior (p<.10) and between gender and injection drug use (p<.10)., Conclusions: The findings support a need for drug treatment programs that include specialized therapies for those who suffered childhood abuse and neglect experiences.

Background: Experimental studies have shown that doxofylline is endowed with a remarkable bronchodilator activity with less extra-respiratory effects than theophylline. This trial was designed to compare the efficacy and safety of doxofylline, theophylline, and placebo in patients with chronic reversible bronchial asthma., Material/methods: Three hundred forty-six patients were randomly assigned to a 12-week oral treatment with either doxofylline 400 mg t.i.d. (high dose), doxofylline 200 mg t.i.d. (low dose), theophylline 250 mg t.i.d. (active control) or placebo. Pulmonary function tests (PFTs) were performed biweekly. Patients kept records of peak flow meter (PFM) measurements, asthma attack rate and beta-2-agonist use (albuterol)., Results: Changes in FEV1 2 hours after the administration of treatments versus baseline exhibited statistically significant differences between doxofylline 400 mg t.i.d. and placebo and between theophylline and placebo. Similar differences were monitored on the other variables (FVC, PFER, FEF(25-75%). Asthma attack rate and use of albuterol decreased remarkably with doxofylline 400 mg t.i.d. and theophylline. There were few statistically significant differences between doxofylline 200 mg t.i.d. and placebo. Significantly more patients had to interrupt treatment because of adverse events under theophylline than under doxofylline 400 mg t.i.d. (p=0.001). With doxofylline 400 mg t.i.d., the number of patients treated to spare one drop-out due to theophylline was 5., Conclusions: This study provides evidence that doxofylline 400 mg t.i.d. is an effective treatment for relieving airway obstruction and displays a better safety profile with respect to theophylline 250 mg t.i.d. with a favorable risk-to-benefit ratio.

Pulmonary junction tests (PFTs) are normally performed prior to methacholine inhalation challenges (MICs). In contrast to normal baseline spirometry (FEV1, FEF25%-27%, FVC), we have observed patients with positive MICs having shortened forced expiratory times (FET100%) in the baseline pre-MIC PFT. We prospectively evaluated the correlation of abnormalities in baseline pre-MIC FET100% in patients who have positive vs. negative MICs. Prospective analysis of baseline pre- MIC FET100%, and MIC results in suspected asthmatics with normal lung exams, spirometry and chest x-rays. Using a PC20 FEV1 of < or =8mg/ml methacholine there were 115 positive and 69 negative MICs. The mean (+/-1 SD) FET100% in the positive MIC group was 3.57+/-1.68 sec vs. 4.73+/-1.60 sec in the negative group. The difference in these means was statistically significant (p <0.0001). There was a statistically significant difference in the incidence of FET100% <4sec in the positive (55.65%) vs. the negative (30.43%) MIC group, p<0.001. There was also a statistically significant difference in the incidence of positive MIC in FET100% <4sec (75.29%) vs. FET100%, > or =4sec (51.52%), p< 0.001. Our results suggest that in our highly selected, well-characterized population, FET100.% <6sec is common and FET100% <4 sec correlates with an increased likelihood of having a positive MIC.

Introduction: Retention in a Methadone Maintenance Treatment Program (MMTP) is predictive of abstaining from heroin and has other benefits. Many individuals leave treatment before they experience these positive outcomes., Objective: This research project targeted MMTP drop-outs with an intervention designed to assist them in returning to drug treatment., Methods: Subjects who had left MMTP within the prior 12 months were randomly assigned to intervention or comparison groups. The 3-month long intervention consisted of street outreach, cognitive behavioral groups, and individual counseling. Data were analyzed for 175 subjects who were out of treatment at baseline and who returned for a 6-month follow-up interview (Intervention group, N=111; Comparison group, N=64)., Results: A total of 87% of subjects assigned to the intervention condition participated in at least one component. Intervention subjects who attended two or more cognitive behavioral group sessions were more likely than those who attended 0-1 sessions or those in the comparison group to have returned to treatment during the 6 month follow up time period (72 vs. 53 vs. 50%, respectively, P<0.05, chi square test)., Conclusion: MMTP drop-outs need not be lost to the drug treatment system if special efforts are made to engage them in interventions developed to encourage treatment re-entry.

The New York City injection drug user acquired immunodeficiency syndrome (IDU AIDS) epidemic accounts for almost one quarter of AIDS cases in IDUs in the United States. Recent studies have reported declines in seroprevalence and risk behaviors among IDUs in New York City during the 1990s. These trends, however, are based on studies primarily conducted in the city's central borough of Manhattan. This article analyzes data from all five boroughs of New York City to examine trends over phases of the epidemic and to determine the level of prevention services available; an exploratory qualitative study was also conducted to assess access to prevention services and injection practices in areas in the "outer boroughs." Findings indicated that (1) borough differences in services and behaviors existed from early in the epidemic; (2) services have been concentrated in Manhattan; and (3) declines in seroprevalence were greatest among Manhattan-recruited IDUs. Enhancing access to services for IDUs in the boroughs outside Manhattan may be needed to continue the positive trends in all areas of New York City.

Background: Aeroallergen sampling provides information regarding the onset, duration, and severity of the pollen season that clinicians use to guide allergen selection for skin testing and treatment., Objective: This atmospheric survey reports: 1) airborne pollen contributors in Philadelphia, Pennsylvania (1991 to 1997) and suburban Cherry Hill, New Jersey (1995 to 1997); 2) pollen onset, duration, and peak level; and 3) the relationship between airborne pollen and selected meteorologic variables., Methods: At both locations, separated by 11 km. sampling was performed with a volumetric Rotorod Sampler (Sampling Technologies, Minnetonka, MN)., Results: In Philadelphia and Cherry Hill, respectively, 3-year average measurements included 75.0 and 74.2% tree pollen, 10.2 and 8.3% grass pollen, and 14.8 and 17.5% weed pollen. Prominent airborne pollen taxa were Acer, Quercus, Betula, Pinus, Cupressaceae, Poaceae, Ambrosia, and Rumex. The tree, grass, and weed pollen seasons extended from mid-March to mid-June, late April to mid-June, and mid-August to late September, respectively. A secondary Poaceae pollen peak occurred in September. There was a statistically significant correlation between simultaneous weekly average pollen levels in Philadelphia and in Cherry Hill (Acer, r(p) = 0.987, Quercus, r(p) = 0.645, Betula, r(p) = 0.896, Pinus, r(p) = 0.732, Cupressaceae, r(p) = 0.695, Poaceae, r(p) = 0.950, Ambrosia, r(p) = 0.903, and Rumex, r(p) = 0.572, P <0.001). Daily Poaceae pollen levels were positively influenced by same-day high temperature (r(s) = 0.333 in Philadelphia and r(s) = 0.426 in Cherry Hill, P < 0.05). Daily Ambrosia pollen levels were inversely influenced by same-day total precipitation (r(s) = -0.174 in Philadelphia and r(s) = -0.257 in Cherry Hill, P < 0.05)., Conclusions: This is the first volumetric survey performed in either Philadelphia or Cherry Hill. Copious amounts of airborne pollen were seen from late April to early May and in early September. Pollen onset, duration, and year-to-year variability were similar at both sites. An awareness of local aeroallergen patterns is critical in the effective testing and treatment of atopic individuals.

Study Objectives: The validity of peak expiratory flow variation (PEFvar) as defined by National Heart, Lung, and Blood Institute (NHLBI) guidelines as a diagnostic tool for suspected asthma or its comparative value to methacholine inhalation challenge (MIC) or postbronchodilator (BD) FEV(1) responses has not been formally assessed. We prospectively analyzed the correlation of 28 different PEFvar indexes (including 4 NHLBI-compatible indexes) with MIC and pre-BD and post-BD FEV(1) responses in suspected asthmatic subjects with normal findings on lung examination, chest radiography, and baseline spirometry., Design: Participants were asked to record peak expiratory flow four times daily for 2 to 3 weeks, followed by an MIC. During a minimum 6-month follow-up period, a clinical diagnosis of asthma was made or ruled out based on testing results and response to antiasthma therapy., Setting: Medical school-affiliated subspecialty private practice of allergy, asthma, and immunology., Participants: One hundred twenty-one suspected asthmatic patients with normal findings on lung examination, chest radiography, and baseline spirometry., Measurements and Results: Fifty-seven subjects completed both the peak flow diary and the MIC and were accepted for statistical analysis. There were no statistically significant correlations between any peak expiratory flow index and MIC. Among the three diagnostic tools evaluated, MIC had the highest sensitivity (85.71%). All the PEFvar indexes and post-BD responses had low sensitivity and high false-negative rates., Conclusions: PEFvar and post-BD FEV(1) responses are poor substitutes for MIC in the assessment of patients with suspected asthma with normal findings on lung examination, chest radiography, and spirometry. Our findings warrant a reconsideration of the NHLBI guidelines recommendation of the utility of PEFvar as a diagnostic tool for asthma in clinical practice.

New entrants to methadone maintenance treatment programs (MMTP) have been reported to have different drug use patterns than re-admissions. This study assesses differences between 211 re-admissions and 128 new admissions to a NYC MMTP. Those new to MMTP were found to be less likely to have ever injected drugs, have used more types of drugs, and used heroin at higher frequencies in the 30 days prior to admission. Within the first three months of treatment, new admissions dropped out at a higher rate than the re-admissions (31% vs. 20%, p < 0.05). The most frequent reasons for dropout, for both groups, included "lost to contact" and incarceration. Further research on strategies to address polydrug use of MMTP admissions is needed. Efforts to identify concerns of new admissions early in treatment, and programs to continue drug treatment services to incarcerated clients, are indicated.

Time in drug treatment has been shown to be one of the best predictors of post-treatment success. Since as many as half of the enrollees leave methadone treatment during the first year, the project described in this article was designed to test the effectiveness of an alternative program for individuals who have recently dropped out of methadone maintenance treatment. The goals of this "Alternative Program" are to help participants re-connect with formal drug treatment and other community or medical programs, reduce their HIV risk behavior, decrease or eliminate drug use, join self-help groups, and obtain entitlements. Program components include: contacts by local outreach workers, cognitive-behavioral relapse-prevention group counseling, and individual counseling for needs assessment and referral. This paper describes the basis for development of the intervention, summarizes the methodology being used, and provides preliminary data on participation in the Alternative Program.

Many studies have found that the longer a drug user remains in treatment, the more positive the outcome. The majority of studies on the effects of time in treatment have followed subjects from the time they enter treatment. The subjects of the present study are injection drug users and crack users who were out of treatment at the time of their recruitment to the study. Between the initial and six-month follow-up interviews, some chose to enroll in drug treatment. The more time a subject spent in treatment during the follow-up period, the more likely it was that s/he was not using heroin or cocaine at follow-up (OR=.51; 95% C.I., .39-.67; p<.001). Unlike the results of some prior studies, positive effects of time in treatment were found even when time in treatment was less than 90 days. The findings of the present study strongly suggest that treatment is beneficial even for those who remain for less than 90 days. Those who provide treatment services to drug users should attempt to maintain contact with dropouts, and support their return to treatment.

Long-term glucocorticoid (GC) therapy has been instrumental in decreasing morbidity and mortality in a variety of chronic inflammatory diseases, including persistent asthma. Long-term GC therapy is also widely prescribed for COPD. One of the important and often unrecognized side effects of chronic GC therapy is secondary osteoporosis. The risk of GC-induced bone loss is roughly correlated with daily dose, duration, and total cumulative lifetime dose of GC treatment. Oral prednisone increases the risk of bone loss and fracture. High doses of inhaled GCs may also increase the risk of osteopenia/osteoporosis, but the risk appears to be less than that associated with oral GCs. Hormone replacement therapy, oral and parenteral bisphosphonates, supplemental calcium and vitamin D, calcitonin, and fluoride compounds have been used, experimentally, in the management of GC-induced bone loss. Asthma and COPD specialists are key prescribers of oral and inhaled steroids and are likely to encounter patients with significant bone loss. Despite known risk factors and the availability of reliable diagnostic tools to recognize bone loss, the opportunity to slow, reverse, and treat bone loss is often missed. We present a review of the current literature regarding the incidence, treatment, and prevention of osteopenia/osteoporosis secondary to chronic GC therapy in adult asthma and COPD patients. Guidelines are presented regarding the identification of patients at risk for developing GC-induced secondary bone loss, and therapeutic alternatives are discussed.

Background: Many clinicians are reluctant to prescribe inhaled corticosteroids because of concerns over potential effects on the hypothalamic-pituitary-adrenal axis., Objective: The purpose of this study was to compare the adrenal responses to 6-hour cosyntropin infusion after treatment with fluticasone propionate aerosol, triamcinolone acetonide aerosol, prednisone, and placebo for 4 weeks, a sufficient time interval to assess any effects on the adrenal response to stress., Methods: This double-blind, triple-dummy, randomized, placebo-controlled study was conducted in 128 patients to evaluate adrenal response to 6-hour cosyntropin infusion (a clinically relevant method for evaluating adrenal function) after 28 days of treatment with fluticasone propionate aerosol 88 microg or 220 microg twice daily, triamcinolone acetonide aerosol 200 microg 4 times daily or 400 microg twice daily, prednisone 10 mg once daily, and placebo., Results: After 28 days of treatment, mean plasma cortisol response to cosyntropin over 12 hours after initiation of the 6-hour infusion was similar among fluticasone, triamcinolone, and placebo groups; cortisol response was significantly (P <.05) reduced after treatment with prednisone compared with the other treatment groups. Mean 8-hour area under the plasma cortisol concentration-time curves and peak plasma cortisol concentrations were significantly (P

Objectives: This study assessed the relation between year of recruitment into an AIDS prevention project and likelihood of engaging (yes/no) in injection risk behaviors., Methods: In total, 834 injection drug users were recruited over a 44-month period (January 1992-August 1995) in New York City. Logistic regression was used to examine trends in three behaviors, across four successive annual cohorts: using needles/syringes that were previously used by another person, using injection supplies (e.g., cookers, cotton, rinse water) that had been previously used, and giving or lending of used needles/syringes to another person., Results: Significant (p < .0001) decreasing trends occurred in two behaviors: giving or lending of used needles/syringes to another person and use of injection supplies that had been used by another person. Sample characteristics were generally consistent over time and did not obviate significant injection risk trends., Conclusions: Decreasing trends in injection risk behaviors could not be explained by changing sample characteristics. Even though some injectors report engaging in risky injection practices, the confluence of numerous AIDS prevention efforts in the 1990s has contributed to an overall reduction in the likelihood of such behaviors.

Crack cocaine users are at high risk for HIV, with higher frequency crack users engaging in higher rates of HIV-related sexual risk behaviors. This study will assess the variables impacting changes in crack use frequency. Out-of-treatment crack users were street recruited in East Harlem, NY. Subjects (n = 727) were 33% female, 91% minority, and 28% reported recent drug injecting. Baseline and 6-month follow-up interviews were administered. There was a significant reduction in crack use over time (p < .0001). Subjects were categorized according to five groups, based on their change in level of crack use between the two interviews, to predict those who stopped, maintained, or changed their level of use. Discriminant analyses identified six variables as the best predictors of the five groups, including having been in drug treatment since baseline and having been a drug injector (both related to reduced levels of crack use). The overall reduction in crack use for the sample masked the fact that important subgroups remained at high use levels or increased their use. The identification of subgroups who may be most resistant to reducing drug use can be helpful in developing more effective interventions.

Background: For more than 70 years, the coexistence of asthma and paranasal rhinosinusitis has been noted in the medical literature. Causal relationships have been proposed but not proved. To date, limited evidence exists suggesting that asthma improves after surgical correction of rhinosinusitis., Objective: To determine whether asthma control improved after first-time functional endoscopic sinus surgery (FESS)., Patients and Methods: A retrospective medical record analysis was performed on 13 patients with chronic bronchial asthma who underwent FESS for medically refractory chronic rhinosinusitis. Patients received comprehensive asthma care before and after FESS (mean, 19.3 and 33.1 months, respectively). Outcomes analyzed included pre- and post-FESS individual and group mean asthma symptom scores, medication use scores, pulmonary function test results, and emergency department visits or hospital admissions for asthma. Patient medical records were obtained from a private allergy-immunology practice affiliated with a medical school. The surgical procedure was performed at a tertiary care teaching hospital by a single ear, nose, and throat surgeon (R.L.)., Results: Following FESS, there was no statistically significant change in group mean asthma symptom scores, asthma medication use scores, pulmonary function test results, and the number of emergency department visits or hospital admissions. Only a few patients demonstrated statistically significant improvement after FESS in asthma symptom scores (1 patient), medication use scores (1 patient), or pulmonary function test results (2 patients)., Conclusions: The data do not support the hypothesis that first-time FESS for medically refractory chronic rhinosinusitis in adult patients with chronic asthma leads to reduced postoperative asthma symptoms or asthma medication use or improved pulmonary function. Based on this limited study, a reexamination of the benefits of sinus surgery to coexisting asthma is in order.

Aims: Drug scenes (social and spatial drug-using and drug-selling environments) have complex role structures. Many drug injectors earn money or drugs as drug or syringe sellers, hit doctors (people who help others to inject) commercial sex workers, or in other roles. This paper aims to measure "role behaviors" of drug injectors; describe which drug injectors are more likely to engage in such role behaviors; and to determine whether roles are related to elements of HIV risk., Design: Cross-sectional study of drug injectors., Setting: Bushwick, a section of Brooklyn, New York, a major location for injection drug use and drug sales., Participants: Seven hundred and sixty-seven street-recruited drug injectors., Measurements: Participants were interviewed about their roles, behaviors, socio-demographics and risk networks; sera were collected and assayed for HIV and hepatitis B core antibody., Findings: Socio-demographic variables are related to role-holding in complex ways. Economic need is generally associated with engaging in drug-scene role behaviors. Holders of these roles are at greater behavioral and network risk for HIV and other blood-borne infections than are other drug injectors. They also engage in extensive communication with other drug users, including discussion of HIV risk reduction., Conclusion: Role behaviors can be measured in quantitative studies, and seem to be related to HIV risk. Role-holders may be strategic targets for risk-reduction campaigns. It seems feasible and advisable to measure drug scene role-holding in research on drug users.

Background: Attempts to delineate efficacy and safety differences among inhaled corticosteroids have been difficult because of the lack of well-controlled, comparative studies reported in the medical literature., Methods: A randomized, double-blind, double-dummy study was conducted in 24 outpatient centers. A total of 291 male and female patients at least 12 years of age with asthma (FEV1 between 50% and 80% of predicted value), who had previously received maintenance therapy with beclomethasone dipropionate or triamcinolone acetonide, were switched to treatment with fluticasone propionate powder (250 microg twice daily), triamcinolone acetonide aerosol (200 microg four times daily), or placebo for 24 weeks., Results: Mean increase in FEV1 from baseline to end point was significantly (p = 0.009) greater in patients switched to treatment with fluticasone compared with patients switched to treatment with triamcinolone (0.27 L and 0.07 L, respectively). At end point, mean increase in morning peak expiratory flow from baseline was 21 L/min with fluticasone compared with mean decreases of 6 L/min and 28 L/min with triamcinolone and placebo, respectively (p < 0.001 vs triamcinolone and placebo). Supplemental rescue albuterol use decreased by 30% from baseline with fluticasone (p < 0.05 vs triamcinolone and placebo) compared with triamcinolone (6%) or placebo (increased by 50%). The percentage of patients withdrawn from the study because they met predefined lack-of-efficacy criteria was higher with placebo (60%) and triamcinolone (27%) than with fluticasone (17%). Incidence of adverse events and low morning plasma cortisol concentrations were similar across treatment groups except for oral candidiasis (p = 0.035, fluticasone vs placebo)., Conclusion: Fluticasone propionate powder twice daily (500 microg/day) was superior in efficacy to triamcinolone acetonide aerosol four times daily (800 microg/day) in patients with persistent asthma.

Background: Fluticasone propionate, an inhaled corticosteroid with negligible systemic bioavailability via the oral route, is efficacious in the treatment of asthma when administered via metered-dose inhaler., Objective: To evaluate the efficacy and safety of inhaled fluticasone propionate powder in patients with moderate asthma previously treated with an inhaled corticosteroid., Methods: This was a randomized, double-blind, placebo-controlled, parallel-group, multicenter study of 342 adolescent and adult patients with moderate asthma [forced expiratory volume in 1 second (FEV1) between 50% and 80% of predicted] treated previously by beclomethasone dipropionate or triamcinolone acetonide. Patients received fluticasone propionate powder 50 micrograms, 100 micrograms, 250 micrograms, or placebo via a breath-actuated inhalation device, the Diskhaler, twice daily for 12 weeks., Results: Patients in the fluticasone propionate groups experienced a mean increase from baseline to endpoint in FEV1 ranging from 0.43 L to 0.47 L. Patients in the placebo group experienced a mean decrease from baseline of 0.22 L (P < .001). The probability of patients remaining in the study over time without developing signs of exacerbating asthma was significantly greater in the fluticasone propionate groups than in the placebo group (P = .001). Asthma symptom scores, supplemental rescue albuterol use, and number of nighttime awakenings due to asthma requiring treatment also improved significantly with all fluticasone propionate treatment regimens compared with placebo (P < .001). There were no statistically significant differences at endpoint among the three fluticasone propionate groups. No serious drug-related adverse events occurred., Conclusions: Fluticasone propionate powder (50, 100, and 250 micrograms) was well-tolerated and significantly improved lung function in patients with moderate asthma.

This paper traces the development of a new technology, the Interactive Video-Questionnaire, for interviewing Deaf persons by using manually signed questionnaires. After encountering numerous obstacles to conducting surveys with Deaf persons about substance abuse using the same methods typically used with hearing persons, the researchers, with a Small Business Innovative Research grant from the National Institute on Drug Abuse, piloted a survey method that uses videodisc and bar code readers to present survey questions signed on screen in American Sign Language and Signed English. Following consultations with Deaf participants, deficiencies of this method were identified and corrected. An interactive multimedia program was created in Phase II of this research effort that offered questions visually in American Sign Language, Signed English, or Speechreading. All questions were subtitled in written English, with Touchscreen entry and automatic data capture and storage. The potential exists for many important uses of the Interactive Video-Questionnaire.

In a cross-sectional study of 174 new injecting drug users (IDUs) in New York City who had injected for < or = 6 years, we examined whether those who both share syringes and have personal risk networks that include high-risk injectors are particularly likely to be infected with HIV. Subjects were street recruited between July 1991 and January 1993, were interviewed about their risk behaviors in the prior 2 years and their personal risk networks with other IDUs in the prior 30 days, and were tested for HIV; 20% were HIV seropositive. Among those who both shared syringes and had a personal risk network member who injected more than once a day, 40% were HIV seropositive (versus 14% for others, p < 0.001). In simultaneous multiple logistic regression, the interaction of both sharing syringes and having a personal risk network member who injected more than once a day remained independently and significantly associated with being HIV seropositive (OR, 3.57; 95% CI, 1.22, 10.43; p < 0.020), along with Latino race/ethnicity and exchanging sex for money or drugs. These findings suggest that the combination of sharing syringes with having a high-risk personal network is a risk factor for HIV infection among new IDUs. Studies of risk factors for HIV infection among new IDUs and interventions to reduce the spread of HIV among them should focus on their risk networks as well as their risk behaviors.

While most studies of AIDS risk behavior rely on self-reports, few studies have assessed the reliability of these reports. The present study examines self-reports of drug-related and sexual risk behavior among pairs of injecting drug users (IDUs) recruited from the streets in New York City. Since both members of the pair were interviewed, it was possible to compare their responses in order to assess reliability. Subjects reported on their contacts' demographic data (age, gender, race/ethnicity) and on shared risk behaviors, including syringe sharing. Despite the private and/or illegal nature of AIDS risk behaviors, IDU subjects were generally reliable in their reports of both demographic and AIDS risk behaviors.

We retrospectively analyzed 198 methacholine inhalation challenges (MICs) of symptomatic patients with normal results of lung examinations, spirometry, and chest radiographs. During MIC, five parameters (FEV1, FEF25-75%, FVC, sGaw, TGV) were measured. Using established changes in these parameters at < or = 8 mg/ml methacholine, there were 175 positive tests (no false positives) and 23 negative tests (15 true negatives, 5 false negatives, and 3 unavailable for follow-up). The MIC sensitivity determined by FEV1 responses was significantly lower than the sensitivity using responses in either three (FEV1, FEF25-75%, and FVC; p < 0.001) or five (FEV1, FEF25-75%, FVC, sGaw, and TGV; p < 0.001) parameter sets. Sensitivities were 60.6 percent, 91.1 percent, and 97.2 percent, respectively. All positive MICs (100 percent) were identified by examining changes in the five-parameter set vs 97.3 percent in the three-parameter set; it was a significant difference at p < 0.01. We conclude that the measurement and analysis of non-FEV1 parameters in addition to FEV1 significantly increases the sensitivity of the MIC.

Human T-cell leukemia virus type I (HTLV-I) has been causally linked to adult T-cell leukemia/lymphoma and tropical spastic paraparesis/HTLV-I-associated myelopathy. Few seroprevalence studies have been carried out in the United States. Because of the number of reports of adult T-cell leukemia/lymphoma and tropical spastic paraparesis/HTLV-I-associated myelopathy in blacks from central Brooklyn, New York, we decided to initiate a seroprevalence study in this community. Intravenous drug users and male homosexuals were excluded. A total of 480 individuals from medical clinics and health fairs were surveyed via questionnaire, and their sera were assayed for HTLV-I/II antibody by two laboratories. An overall seroprevalence rate was 21/480 (4.4%). This is almost 200 times greater than a study of a national sample of U.S. blood donors. Rates were similar for individuals originating from the United States and the Caribbean. Nine of the 21 seropositive individuals returned for further testing. Polymerase chain reaction assays revealed that 8 were positive for HTLV-I and 1 for HTLV-II. Although this group may not be representative of the "normal" black population of central Brooklyn, the high seroprevalence rate necessitates that the incidence of HTLV-I-associated illnesses be determined in this community.

Background: In syringe-mediated drug-sharing (backloading), injecting drug users (IDU) use their syringes to mix drugs and to give measured shares to other IDU by squirting drug solution into the syringes of other IDU. Backloading has been discussed as a potential HIV risk factor, but its role as an HIV transmission route has not been established empirically., Methods: Six hundred and sixty IDU who had injected drugs in the previous 2 years were street-recruited from Bushwick, New York City through chain referral, tested for HIV antibody and interviewed about sexual and drug-risk behaviors., Results: Receiving drugs via backloading in the previous 2 years was reported by 24.5% of the subjects. These subjects had significantly higher HIV seroprevalence than those who did not receive drugs by backloading (odds ratio, 2.2; 95% confidence interval, 1.5-3.1). Backloading remained positively and significantly associated with HIV seropositivity in stepwise logistic regression, and in a series of simultaneous logistic models controlling for sociodemographic variables and for sexual and drug risk variables., Conclusions: Backloading can be a route of HIV transmission among IDU and should be incorporated into risk-factor studies and HIV transmission modeling. Many IDU who avoid other high-risk drug-injection practices may overlook the risk of backloading. HIV prevention programs should warn IDU against syringe-mediated drug-sharing and work together to develop ways to avoid it.

The loss of HLA antigens by neoplastic cells is considered important for tumor growth and metastasis, since it may allow tumors to escape immune surveillance. We studied the expression of HLA class I and II antigens in the colons of 10 patients with familial adenomatous polyposis (FAP), a condition which leads inevitably to colorectal cancer. Expression of HLA class antigens was studied by immunohistochemistry in (a) adenomas from patients with FAP, (b) histologically normal mucosa distant from the adenomas, and (c) histologically normal colonic mucosa from normal subjects. The expression of HLA class I and II antigens was decreased in histologically normal mucosa from FAP patients compared to normal controls. Adenomas showed a similar but quantitatively more pronounced reduction (or loss) of HLA antigen expression. The reduction of HLA expression in adenomas was comparable to that observed in sporadic colon carcinomas. This generalized suppression of HLA gene expression in the colon of FAP patients, which precedes the onset of overt histological manifestations of neoplasia, may be an important early event in colon carcinogenesis.

This article is highlighted by the finding of striking cervical lymphadenopathy in a patient with acquired hyper-IgM syndrome and the pathologic description of the involved nodes. Routine hematoxylin-eosin stains demonstrated the presence of idiopathic necrotizing granulomas in the nodal tissue, a finding not previously reported in this syndrome. Immunoperoxidase techniques were used to further characterize these granulomas and delineate the cellular composition of the nodal architecture. We found that the necrotizing granulomas consisted of a peripheral rim of Ia positive palisaded, epithelioid histiocytes and central areas of debris and scattered inflammatory cells that were T11 positive. In the uninvolved areas of the node, we observed a lack of IgG-bearing lymphocytes in germinal centers as well as an absence of IgG-containing and decreased IgA-containing plasma cells in interfollicular areas. In conjunction with these in situ observations, there was a lack of IgA and IgG immunoglobulin-secreting cell responses in pokeweed mitogen-stimulated cultures of the patient's peripheral blood mononuclear cells. Unique features of this article include: (1) the association of necrotizing granulomas with the hyper-IgM syndrome and (2) the use of monoclonal antibodies to characterize the distributions of nodal lymphocytes in a patient with this disorder.

Eosinophilic fasciitis has been reported to be a syndrome distinct from progressive systemic sclerosis, due to the absence of Raynaud's phenomenon, visceral disease, and autoantibodies as well as steroid responsiveness and an abnormal histopathologic appearance that primarily involves the lower subcutis and fascia. More recent studies, however, have noted considerable overlap in the clinical, pathologic, and laboratory features of these two entities. We report a case that further blurs the distinction between eosinophilic fasciitis and progressive systemic sclerosis.

This is the first case report to our knowledge of superior vena cava syndrome and lethal, massive pulmonary embolus associated with a noniatrogenic right atrial mural thrombus. In situ, superior vena cava thrombosis was demonstrated by technetium Tc 99m nucleotide mediastinal flow scan and superior vena cava venography. Necropsy confirmed in situ superior vena cava thrombosis as well as trichamber mural thrombi and a massive pulmonary embolus. Intravenous streptokinase therapy for superior vena cava thrombosis was unsuccessful.

A practical approach for assessing patient education needs in the ambulatory care setting was developed, tested, and administered to 100 individuals with four non-acute clinical problems. The approach allowed collection, with a single instrument, of a range of information pertinent to the management of a wide mix of disorders. Knowledge about diagnosis, medications, nonmedicinal procedures, emergency situations, and prognosis was collected as well as self-estimation of knowledge and personal information needs.While the assessment can be conducted by a physician, nurse, mid-level practitioner, or health educator in approximately five minutes, it can also be conducted in approximately ten minutes by other appropriately trained personnel. The information gained is useful to clinicians, health educators, and administrators. This practical approach to the assessment of patient learning needs is considered to have applicability for numerous conditions and a variety of clinical settings. The condensed patient learning needs assessment tool is provided (Table 1).