Asunto(s)
Trastornos Relacionados con Sustancias , Humanos , Recurrencia , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/genética , Trastornos Relacionados con Sustancias/psicología , Trastornos Relacionados con Sustancias/terapia , Terminología como AsuntoRESUMEN
BACKGROUND: Primary cutaneous aspergillosis is an uncommon finding in patients with acquired immunodeficiency syndrome (AIDS); only 13 cases have been reported in the literature. OBSERVATIONS: We describe 11 patients with primary cutaneous aspergillosis and AIDS. There does not seem to be an age, sex, race, or human immunodeficiency virus risk factor predisposition. This is a late manifestation of AIDS; patients typically have low CD4 counts (<0.050 x 10(9)/L [<50/microL]) and other AIDS-defining illnesses. The most frequent presentation is in patients with cytomegalovirus disease and neutropenia caused by ganciclovir therapy. Lesions developed at the site of occlusive dressings for an indwelling intravenous catheter site in 10 patients. Neutrophil counts may be normal at the time of diagnosis. A minor presentation is in the patient without neutropenia as a result of traumatic inoculation. Histological findings and/or culture results are required for diagnosis. Patients develop cutaneous lesions despite prophylactic therapy with fluconazole. Lesions can be treated with excision and lifelong therapy with itraconazole. CONCLUSION: Because of the potential morbidity and mortality of cutaneous aspergillosis, a high level of suspicion and prompt institution of therapy is required.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/complicaciones , Aspergilosis/complicaciones , Dermatomicosis/complicaciones , Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Adulto , Antifúngicos/uso terapéutico , Aspergilosis/tratamiento farmacológico , Aspergilosis/patología , Aspergilosis/cirugía , Catéteres de Permanencia/efectos adversos , Dermatomicosis/tratamiento farmacológico , Dermatomicosis/patología , Dermatomicosis/cirugía , Humanos , Itraconazol/uso terapéutico , Masculino , Persona de Mediana Edad , Apósitos Oclusivos/efectos adversosRESUMEN
Patients with substance abuse problems are common in general medical practice and include people of all ages and socioeconomic groups. Initial diagnosis and treatment of addiction problems are often done by the primary care practitioner before referral to a specialist. This article provides information to help in recognition of addiction, guidelines for treatment of intoxication and withdrawal of various drugs of abuse (such as opioids, sedative-hypnotics, stimulants, hallucinogens, and volatile inhalants), and techniques for brief intervention as well as long-term care of substance-abusing patients. The physician can be a powerful influence for getting the patient to accept treatment, especially when the physician is empathic without being judgmental. Addiction is a chronic disorder with remissions and relapses like any other chronic disease, so exacerbations should not be seen as failures but as time to intensify treatment. Patients with substance abuse problems can be frustrating to treat, but it can also be a rewarding experience when a physician helps a substance-abusing patient return to normal and productive functioning in society.
Asunto(s)
Rol del Médico , Atención Primaria de Salud , Trastornos Relacionados con Sustancias , Enfermedad Aguda , Estimulantes del Sistema Nervioso Central/efectos adversos , Enfermedad Crónica , Diagnóstico Diferencial , Alucinógenos/efectos adversos , Humanos , Hipnóticos y Sedantes/efectos adversos , Trastornos Relacionados con Opioides/diagnóstico , Trastornos Relacionados con Opioides/terapia , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/terapiaRESUMEN
Tramadol HCl, marketed as Ultram in the USA, was introduced as a non-scheduled drug in April 1995 based on the assumption that the risk of abuse was sufficiently low to warrant a non-scheduled status. However, approval was contingent upon the development of an innovative proactive surveillance program, to be overseen by an independent steering committee, which would detect unexpectedly high levels of abuse. The postmarketing surveillance program consisted of systematic collection and scientific evaluation of reports of suspected abuse in high-risk populations surveyed through an extensive key informant network of drug abuse specialists and all spontaneous reports of abuse received through the FDA MedWatch system. Methods to estimate the number of patients prescribed tramadol were also developed. Monthly rates of abuse were calculated as an index of the risk-benefit ratio (i.e., abuse cases per 100,000 patients prescribed the drug). The data for the 3 years since the drug was introduced show that the reported rate of abuse has been low. Although a period of experimentation seemed to occur in the first 18 months after its introduction--which reached a peak rate of approximately two cases per 100,000 patients exposed--during the 2 year period prior to June 1998, the reported rate of abuse has significantly (P = 0.011) declined, reaching levels of less than one case per 100,000 patients in the last 18 months. The overwhelming majority of abuse cases (97%) have been found to occur among individuals with a history of substance abuse and the abuse has been confined to isolated pockets around the country-notably none of which have significant populations of street drug abusers. Thus, the data support the decision not to schedule tramadol and, furthermore, suggest that a proactive post-marketing surveillance program can be successfully developed to effectively monitor abuse of new medications.
Asunto(s)
Analgésicos Opioides , Prescripciones de Medicamentos/estadística & datos numéricos , Vigilancia de Productos Comercializados/estadística & datos numéricos , Trastornos Relacionados con Sustancias/epidemiología , Tramadol , Humanos , Medición de Riesgo/estadística & datos numéricos , Trastornos Relacionados con Sustancias/prevención & control , Estados Unidos/epidemiologíaRESUMEN
Traditionally, methadone maintenance therapy has been a once-daily dosing schedule. The current study evaluates the effectiveness of this regimen during pregnancy. A total of 23 pregnant and 16 non-pregnant opioid-dependent patients were studied in two phases to evaluate pregnancy-dependent changes in methadone pharmacokinetics. In the first phase, pregnant patients had a statistically significant higher elimination rate constant (k) and lower half-life compared to non-pregnant controls. In the second phase, the apparent clearance (Cl/F) was significantly greater during pregnancy, with preliminary data suggesting that this observation results from a decrease in the fraction of dose absorbed (F). The implications of these findings on dosing regimens during pregnancy is discussed.
Asunto(s)
Metadona/farmacocinética , Narcóticos/farmacocinética , Trastornos Relacionados con Opioides/rehabilitación , Complicaciones del Embarazo/rehabilitación , Adulto , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Semivida , Humanos , Metadona/administración & dosificación , Metadona/uso terapéutico , Narcóticos/administración & dosificación , Narcóticos/uso terapéutico , Embarazo , Tercer Trimestre del Embarazo/fisiologíaRESUMEN
This study investigated the association between two demographic and two psychological variables and treatment retention for 65 perinatal substance abusers. Subjects who lived in the community while attending day treatment were 6.125 times more likely to drp out than subjects who lived in a program-operated shelter (p < .0001). An interaction was found for pregnancy status and antisocial personality disorder (p < .0478). Subjects who were both pregnant and antisocial were 4.876 times more likely to remain in treatment than those who were neither pregnant nor antisocial. Degree of "treatment resistance," measured by the MMPI Negative Treatment Indicators (TRT) Scale, did not predict dropout. These findings indicate that supportive housing can play an important role in preventing dropout for perinatal substance abusers. Additionally, pregnancy may present a "window" of opportunity for treating a hard to reach population, drug abusing women with comorbid ASP.
Asunto(s)
Pacientes Desistentes del Tratamiento , Complicaciones del Embarazo/epidemiología , Complicaciones del Embarazo/terapia , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/terapia , Adulto , Trastorno de Personalidad Antisocial/epidemiología , Actitud Frente a la Salud , Comorbilidad , Femenino , Humanos , MMPI , Embarazo , Complicaciones del Embarazo/diagnóstico , Psicoterapia , Trastornos Relacionados con Sustancias/diagnósticoRESUMEN
To evaluate the effects of acute cocaine withdrawal on the immune system of pregnant women, we analyzed changes in a panel of cell surface markers and plasma proteins that have immunological importance. The cell surface markers included complement receptors [CR1 (CD35), CR2 (CD21), CR3 (CD11b, CD18)], immunoglobulin Fc receptors [FcgammaRII (CD32), FcgammaRIII (CD16)], proteins important for lymphocyte function [CD3, CD4, CD8, CD19, CD25, CD45RA], and the framework antigen HLA-ABC. We also measured levels of the plasma proteins C3, C4, IgG, IgM, and IgA, along with the cytokine interleukin-2, soluble lymphocyte markers sCD25, sCD4, sCD8, IL-2, and soluble immune complexes. While no significant changes were seen in the levels of plasma proteins, changes paralleling the course of acute withdrawal were seen in complement receptors and immunoglobulin Fc receptors on leukocyte subpopulations. By contrast, proteins important for lymphocyte function were relatively unperturbed. There was an increase in receptor expression at the onset of withdrawal that peaked 3-5 days after last cocaine use, followed by a decrease in expression to initial (pre-withdrawal) levels. These changes in cell surface receptors may reflect altered immune function in the women who were withdrawing from cocaine.
Asunto(s)
Biomarcadores/química , Cocaína/farmacología , Leucocitos/metabolismo , Linfocitos/metabolismo , Receptores de Complemento/efectos de los fármacos , Linfocitos T/metabolismo , Adulto , Femenino , Humanos , Embarazo , Receptores de Complemento/metabolismoRESUMEN
This study tested the ability of the Recovery Attitude and Treatment Evaluator (RAATE; Mee-Lee, Hoffmann, & Smith, 1992) to predict attrition from treatment for pregnant and postpartum substance abusing women. During the first month of treatment, the RAATE was completed by both the clinician and the patient. Three types of discharge status were considered: completion of the treatment program, dropping out of the program, and being administratively discharged. No group differences were found concerning the clinician version of the RAATE. Initial analyses of the patient version revealed that subjects who completed the program had lower ratings of resistance to treatment and continuing care compared to those who dropped out; further analysis suggested that those who completed less than 1 month of treatment exhibited the highest resistance. These results suggest the RAATE is a potentially effective tool for predicting early attrition from substance abuse treatment in this population.
Asunto(s)
Actitud Frente a la Salud , Cooperación del Paciente , Complicaciones del Embarazo/rehabilitación , Psicometría , Trastornos Relacionados con Sustancias/rehabilitación , Adulto , Cuidados Posteriores , Femenino , Humanos , Análisis Multivariante , Pacientes Desistentes del Tratamiento , Valor Predictivo de las Pruebas , Embarazo , Pruebas Psicológicas , Reproducibilidad de los Resultados , Factores de Riesgo , VirginiaRESUMEN
OBJECTIVE: To determine whether there is a demonstrable abnormality in control of breathing in infants of substance-abusing mothers during the first few days of life. METHODS: We enrolled 12 drug-free control infants and 12 infants of substance abusing mothers (ISAMs). These infants experienced otherwise uncomplicated term pregnancies and deliveries. The infants were assigned to a group based on the results of maternal histories and maternal and infant urine toxicology screens. Studies were performed during quiet sleep during the first few days of life. We measured heart rate, oxygen saturations via a pulse oximeter, end-tidal carbon dioxide (ET-CO2) level, respiratory rate, tidal volume, and airflow. The chemoreceptor response was assessed by measuring minute ventilation and the ET-CO2 level after 5 minutes of breathing either room air or 4% carbon dioxide. RESULTS: The gestational ages by obstetrical dating and examination of the infants were not different, although birth weights and birth lengths were lower in the group of ISAMs. Other demographic data were not different, and there were no differences in the infants' median ages at the time of study or in maternal use of tobacco and alcohol. The two groups had comparable baseline (room air) ET-CO2 levels, respiratory rates, tidal volumes, and minute ventilation. When compared with the group of ISAMs, the drug-free group had markedly increased tidal volume and minute ventilation on exposure to 4% carbon dioxide. These increases accounted for the difference in sensitivity to carbon dioxide, calculated as the change in minute ventilation per unit change in ET-CO2 (milliliters per kg/min per mm Hg). The sensitivity to carbon dioxide of control infants was 48.66 +/- 7.14 (mean +/- SE), whereas that of ISAMs was 16.28 +/- 3.14. CONCLUSIONS: These data suggest that ISAMs are relatively insensitive to challenge by carbon dioxide during the first few days of life. We speculate that this reflects an impairment of the chemoreceptor response.
Asunto(s)
Dióxido de Carbono/administración & dosificación , Recién Nacido/fisiología , Efectos Tardíos de la Exposición Prenatal , Respiración/efectos de los fármacos , Pruebas Respiratorias , Dióxido de Carbono/análisis , Dióxido de Carbono/fisiología , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Embarazo , Trastornos Relacionados con Sustancias , Volumen de Ventilación PulmonarAsunto(s)
Metadona/uso terapéutico , Narcóticos/uso terapéutico , Complicaciones del Embarazo/rehabilitación , Trastornos Relacionados con Sustancias/rehabilitación , Animales , Femenino , Humanos , Recién Nacido , Metadona/efectos adversos , Narcóticos/efectos adversos , Síndrome de Abstinencia Neonatal/etiología , Embarazo , Ratas , Síndrome de Abstinencia a Sustancias/etiologíaRESUMEN
Eighty pregnant women (25 substance using, 55 nonusing) from an American prenatal clinic serving lower-income to working-class women responded to questionnaire measures of child-rearing attitudes. The drug users' primary substance of misuse was cocaine (68%), alcohol (16%), amphetamines (12%), or sedatives (4%); polydrug use was documented for 80% of the women. The two (user and nonuser) groups were not different on demographic (age, race, marital status, education, SES, source of income) or obstetrical factors (number of pregnancies, number of children). Drug-using women scored significantly higher on a measure of child abuse potential; more than half scored in the range of clinical criterion for extreme risk. As their babies were not yet born, no actual physical abuse was documented, only a higher potential for abuse. The subgroup who were both drug users and had lower social support scored higher on child abuse potential than all other subgroups. The drug users also had lower self-esteem scores than the nonusers. The two groups did not differ on measures of overall social support, authoritarian/democratic child-rearing beliefs, or affection for the expected baby.
Asunto(s)
Actitud , Maltrato a los Niños/psicología , Drogas Ilícitas , Relaciones Madre-Hijo , Responsabilidad Parental/psicología , Complicaciones del Embarazo/psicología , Psicotrópicos , Apoyo Social , Trastornos Relacionados con Sustancias/psicología , Adulto , Maltrato a los Niños/prevención & control , Femenino , Humanos , Recién Nacido , Inventario de Personalidad , Embarazo , Atención Prenatal , Factores de Riesgo , Autoimagen , Detección de Abuso de SustanciasRESUMEN
Methadone maintenance has been used for decades to treat opioid-dependent pregnant women. The outcomes of pregnancies thus treated are vastly improved over the outcomes of pregnancies complicated by street drug use. Despite its long history of successful use during pregnancy, little is known about the long-term effects of methadone on the fetus and the newborn. Studies done in animals suggest there may be subtle effects on brain and behavior. Only recently have other treatments for opioid dependency during pregnancy been investigated. There is increasing evidence that altering the traditional methadone maintenance protocols may be beneficial, and that tapered withdrawal can be safely achieved under some circumstances.
Asunto(s)
Metadona/uso terapéutico , Trastornos Relacionados con Opioides/complicaciones , Trastornos Relacionados con Opioides/rehabilitación , Complicaciones del Embarazo/terapia , Femenino , Humanos , Metadona/efectos adversos , Embarazo , Resultado del EmbarazoRESUMEN
Forty perinatal substance abusers were administered multiple psychosocial, addiction, and psychological measures before beginning treatment. Results indicate that these patients are limited intellectually, educationally, financially, and emotionally. Psychiatric comorbidity was high, with 45% having non-substance abuse axis I diagnoses and 75% having confirmed (by two or more tests) axis II pathology. The most frequently identified axis I disorders were depression and anxiety. The most frequently detected personality disorders were antisocial, borderline, paranoid, and dependent. The average IQ was 87 (low average range) and nearly one third of the sample were found to be somewhat impaired intellectually. These data suggest that treatment programs must take psychological characteristics into account if they are going to succeed in helping these women achieve and maintain abstinence.
Asunto(s)
Trastornos Mentales/diagnóstico , Complicaciones del Embarazo/diagnóstico , Trastornos Puerperales/diagnóstico , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos de Ansiedad/diagnóstico , Trastornos de Ansiedad/epidemiología , Comorbilidad , Trastorno Depresivo/diagnóstico , Trastorno Depresivo/epidemiología , Escolaridad , Femenino , Humanos , Pruebas de Inteligencia , Trastornos Mentales/epidemiología , Trastornos de la Personalidad/diagnóstico , Trastornos de la Personalidad/epidemiología , Embarazo , Complicaciones del Embarazo/epidemiología , Prevalencia , Escalas de Valoración Psiquiátrica , Pruebas Psicológicas , Trastornos Puerperales/epidemiología , Índice de Severidad de la Enfermedad , Trastornos del Sueño-Vigilia/diagnóstico , Trastornos del Sueño-Vigilia/epidemiología , Clase Social , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/rehabilitaciónRESUMEN
BACKGROUND: Physicians in the general medical setting commonly encounter but rarely counsel patients with dependent or harmful drinking behaviors. We tested whether providing physicians with their patients' results on the alcohol module of the Diagnostic Interview Schedule and counseling directives would prompt them to counsel these patients. METHODS: We randomly assigned 83 first-, second-, and third-year medical residents to receive or not to receive diagnostic information and counseling directives on 214 patients who reported at least one symptom of alcohol impairment as defined in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Using binary logistic regression, we examined the effect of specific covariables on rates of physician counseling. These variables included physician information status, patient gender, and drinking disorder severity and recency. We also examined the effect of physician prompting on counseling of female patients, patients with inactive disorders, and nondependent but harmful drinkers. We determined counseling by post-visit patient interviews. RESULTS: Physician prompting, dependent drinking, and recent disorder activity were significant correlates of physician counseling (P < .05), while male gender was a marginally significant correlate (P = .08). Informed physicians counseled female patients, harmful but nondependent drinkers, and patients with inactive disorders more often than their uninformed colleagues, although only the last variable achieved statistical significance. CONCLUSIONS: Providing physicians with the results of the Diagnostic Interview Schedule and counseling directives resulted in short-term improvement in their rates of counseling patients with a history of dependent or nondependent but harmful drinking. Further research is necessary to determine long-term gains in rates of physician counseling and improvements in the course of these patients.
Asunto(s)
Alcoholismo/terapia , Consejo/estadística & datos numéricos , Pautas de la Práctica en Medicina , Alcoholismo/diagnóstico , Correspondencia como Asunto , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Modelos Logísticos , Masculino , Índice de Severidad de la Enfermedad , Factores SexualesRESUMEN
Drug-abusing (n = 25) and nonusing (n = 55) pregnant women from a publicly supported prenatal clinic were tested for level of social support and of pregnancy anxiety during the last half of pregnancy. Differences found between the groups were fewer than expected. Drug abusers did not differ from nonusers in overall level of social support or in Appraisal, Belonging, or Tangible subscales. Abusers were found to report lower levels of self esteem; lower self esteem was predicted by drug abuse, having more children and lower socioeconomic status. Drug abusers did not differ from nonusers in their overall feelings of pregnancy anxiety, but they did indicate higher fears for themselves and for the baby, and there was a tendency for higher depression and withdrawal.
Asunto(s)
Ansiedad/psicología , Drogas Ilícitas , Atención Prenatal , Psicotrópicos , Apoyo Social , Trastornos Relacionados con Sustancias/psicología , Adolescente , Adulto , Femenino , Humanos , Drogas Ilícitas/efectos adversos , Recién Nacido , Síndrome de Abstinencia Neonatal/prevención & control , Inventario de Personalidad , Embarazo , Psicotrópicos/efectos adversos , Factores de Riesgo , Autoimagen , Trastornos Relacionados con Sustancias/rehabilitaciónRESUMEN
Attention deficits were studied among 67 consecutive admissions to an adult tertiary care in-patient substance abuse unit. Fifty-four patients completed the testing; of these 15 were excluded due to confounding variables. The majority of the remaining 39 subjects had evidence of current and/or childhood attention dysfunction. There was no correlation with current performance and childhood recollection of dysfunction even when the effect of gender, race and alcohol abuse were taken into account. There are intriguing educational and therapeutic implications of the similarities between cognitive impairments of newly sober substance abusers and adults with persistence of attention deficit-hyperactivity disorder (ADHD).