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OBJECTIVE: Both methadone and buprenorphine are effective therapy for heroin dependence. Efficacy is best documented for methadone maintenance therapy, but safety concerns limit its use. Buprenorphine offers lower overdose risk and improved access, but efficacy may be lower. The authors compared adaptive, buprenorphine-based stepped care to optimal methadone maintenance treatment. METHOD: This randomized controlled trial was undertaken 2004-2006. It consisted of a 24-day uniform double-blind induction phase followed by single-blind flexible dosing based on structured clinical criteria, for a total of 6 months. Ninety-six self-referred subjects with heroin dependence were randomly assigned to methadone or to stepped treatment initiated with buprenorphine/naloxone and escalated to methadone if needed. All subjects received intensive behavioral treatment. Primary outcome was retention in treatment. Secondary outcomes were completer analyses of problem severity (Addiction Severity Index) and proportion of urine samples free of illicit drugs. RESULTS: Overall, 6-month retention was 78%. Stepped treatment and methadone maintenance therapy outcomes were virtually identical. Among completers of stepped therapy, 46% remained on buprenorphine/naloxone. Proportion of urine samples free of illicit opiates increased over time and ultimately reached approximately 80% in both arms. Problem severity decreased significantly and uniformly in both arms. CONCLUSIONS: A stepped treatment of heroin dependence as described here appears equally efficacious compared to optimally delivered methadone maintenance therapy. Together with prior data on the advantageous safety of buprenorphine, this suggests that broad implementation of strategies using buprenorphine as first-line treatment should be considered. [ABSTRACT FROM AUTHOR]

This second of two articles on sickle cell disease (SCD) aims to provide advice on nursing care for patients. All health professionals should be aware of the various manifestations of the disease, the life-threatening complications and their optimal management. Prophylactic strategy is of paramount importance as it may avert many possible adverse outcomes. Recurrent episodes of acute, severe pain require frequent hospital admissions. The care of individuals with SCD must extend into the community and take account of domestic, employment and educational issues. Affected pregnant women should be looked after by units experienced in the care of women with this condition. The diagnosis of haemoglobin type is simple and inexpensive and a comprehensive national screening programme to detect SCD in pregnant women and newborn babies was started in April 2002 as part of the Government's broader aims to tackle inequalities in health and community. [ABSTRACT FROM AUTHOR]

Haemoglobinopathies refer to a range of genetically inherited disorders of red blood cell haemoglobin and include sickle cell disorders and thalassaemias. They occur most commonly in populations whose ancestors come from Africa, Asia, Mediterranean Islands, and the Middle and Far East. Haemoglobin (Hb) abnormalities (or haemoglobinopathies) are caused by (i) abnormalities of the protein structure; (ii) imbalanced globin chain production owing to reduced rate of synthesis of normal a or b globin chains; or (iii) a combination of the two. This article will focus on the biological basis of sickle cell disorders and will discuss the history and pathology of the conditions. [ABSTRACT FROM AUTHOR]

Although the care of patients with diabetes is increasingly provided in primary care, there is relatively little information on the prevalence and long-term progression of asymptomatic peripheral arterial disease (PAD) in diabetic populations selected from primary care settings. The aims of this study were to investigate prevalence and progression of PAD in 146 diabetic patients, and to compare mortality with 113 nondiabetic controls over a 7-year period. The prevalence of PAD in individual pedal arteries varied between 28.6% in the right posterior tibial artery to 48.8% in the left peroneal artery. During the 7-year period, 34.25% of the diabetic subjects died, and 17.5% moved to other locations. Of the remaining 70 patients, 35 (50%) showed no change in ankle-brachial index and 35 (50%) did show change. Comparison of risk factors between those who did and did not show evidence of progression revealed (1) a strong, significant, independent association between hyperglycemia (measured by plasma HbA1c) and progression of PAD among the diabetic population; and (2) a strong association between progression of the disease and family history of diabetes and ischemic vascular disease. There was a high death rate (34.25%) among the diabetic group, which was greater than for the age- and sex-matched nondiabetic controls (13.2%) drawn from the same practice. This high mortality was significantly related (P < .001) to the presence of PAD identified during first-year assessment. Once PAD develops in association with diabetes the long-term prognosis is poor and carries a high mortality rate mainly because of cardiovascular and cerebrovascular diseases. Both progression and mortality were significantly related to poor diabetic control. The role of the primary care nurse in assessing such patients by using Doppler-assisted measurements is one that should be expanded with the massive increase in the number of diabetic patients in the coming years. [ABSTRACT FROM AUTHOR]

The level of training and competence in dealing with haemoglobin-opathies (which mainly affect ethnic minorities in the UK) may not be totally adequate among nurses. Nurses indicated that they received little or no information in their teaching for working from a multiracial perspective and what they had learned was through experience and personal research since qualifying as nurses. Knowledge of the biological basis of inheritance, methods of acquisition of thalassaemia and sickle-cell anaemia and the ethnic profile of people affected by these conditions may not be totally adequate among nurses. Many nurses wanted more training, including those who had already received instruction, since this was described as 'far too vague', 'not constructive', 'minimal', or 'embarrassingly insufficient', recommending that instruction be given by a sickle-cell anaemia/thalassaemia counsellor with a contribution from patients. A combination of poor quality, or lack, of instruction, together with time and resource pressures, is responsible for this limited understanding, resulting in insufficient awareness of the health needs of ethnic minorities leading to inequalities in healthcare provision. [ABSTRACT FROM AUTHOR]

This paper describes the establishment of a pilot neighbourhood-based intergenerational programme and its evaluation in one town in England. It sets this in both the context of English intergenerational programmes involving schools and of English social policy. The latter is currently influenced by Putnam's concept of social capital. It argues that intergenerational programmes of all kinds are likely to be useful contributions to the development of social capital. The paper reports how the evaluation of the pilot has lead to the refinement of the original model. The pilot highlighted the need for more systematic measures of the process and outcomes, including the project's contribution to development of social capital. The revised model is being implemented in a number of contrasting neighbourhoods and will be evaluated in both outcome and process terms. These developments will be reported in further articles. [ABSTRACT FROM AUTHOR]