An unusual case of intertrigo in an adult caused by purely cutaneous Langerhans cell histiocytosis

We report a case of persistent intertrigo in an adult, eventually diagnosed as cutaneous Langerhans cell histiocytosis (LCH). It is known that LCH has a predilection for intertriginous areas, however purely cutaneous disease as in our case, is uncommon and usually other systems are affected. Following the report, literature of similar cases is reviewed to determine possible outcomes and to decide on the best possible treatment options.peer-reviewe

Preventing opioid overdoses in Europe:a critical assessment of known risk factors and preventative measures

This report is the outcome of a project into opioid overdoses. The remit was to focus on finding practical methods of overdose prevention. In order to fulfil this remit, a critical review of existing knowledge on overdose prevention was conducted. The report adds value to existing information by developing a methodology to classify and analyse risk and protective factors stratified by those involved (drug users, observers and organisations). The report then assesses the extent to which risk and protective factors can be potentially modified at different levels, e.g. individual, treatment setting, organisational and strategic. The report therefore has the potential to be updated as new information emerges

Profiles of visuospatial memory dysfunction in opioid exposed and dependent populations

Background . Chronic opioid exposure is common world-wide, but behavioural performance remains under-investigated. This study aimed to investigate visuospatial memory performance in opioid-exposed and dependent clinical populations and its associations with measures of intelligence and cognitive impulsivity. Methods . We recruited 109 participants: (i) patients with a history of opioid dependence due to chronic heroin use (n = 24), (ii) heroin users stabilised on methadone maintenance treatment (n = 29), (iii) participants with a history of chronic pain and prescribed tramadol and codeine (n = 28) and (iv) healthy controls (n = 28). The neuropsychological tasks from the Cambridge Neuropsychological Test Automated Battery included the Delayed Matching to Sample (DMS), Pattern Recognition Memory, Spatial Recognition Memory, Paired Associate Learning, Spatial Span Task, Spatial Working Memory and Cambridge Gambling Task. Pre-morbid general intelligence was assessed using the National Adult Reading Test. Results . As hypothesised, this study identified the differential effects of chronic heroin and methadone exposures on neuropsychological measures of visuospatial memory (p < 0.01) that were independent of injecting behaviour and dependence status. The study also identified an improvement in DMS performance (specifically at longer delays) when the methadone group was compared with the heroin group and also when the heroin group was stabilised onto methadone. Results identified differential effects of chronic heroin and methadone exposures on various neuropsychological measures of visuospatial memory independently from addiction severity measures, such as injecting behaviour and dependence status.PostprintPeer reviewe

Compulsivity in opioid dependence

This study was part funded by an unrestricted educational grant provided by Schering-Plough and a grant by an Anonymous Trust. Study support was also provided by the Scottish Mental Health Research Network. AB has received educational grants from Schering Plough and he has received research project funding from Schering-Plough, Merck Serono, and Indivior.Objective: This study aimed to investigate the relationship between compulsivity versus impulsivity and structural MRI abnormalities in opioid dependence. Method: We recruited 146 participants: i) patients with a history of opioid dependence due to chronic heroin use (n=24), ii) heroin users stabilised on methadone maintenance treatment (n=48), iii) abstinent participants with ahistory of opioid dependence due to heroin use (n=24) and iv) healthy controls(n=50). Compulsivity was measured using Intra/Extra-Dimensional (IED) Task and impulsivity was measured using the Cambridge Gambling Task (CGT).Structural Magnetic Resonance Imaging (MRI) data were also obtained. Results: As hypothesised, compulsivity was negatively associated with impulsivity (p<0.02). Testing for the neural substrates of compulsivity versus impulsivity, we found a higher compulsivity/impulsivity ratio associated with significantly decreased white matter adjacent to the nucleus accumbens, bed nucleus of stria terminalis and rostral cingulate in the abstinent group,compared to the other opioid dependent groups. In addition, self-reported duration of opioid exposure correlated negatively with bilateral globus pallidus grey matter reductions. Conclusion: Our findings are consistent with Volkow & Koob’s addiction models and underline the important role of compulsivity versus impulsivity inopioid dependence. Our results have implications for the treatment of opioid dependence supporting the assertion of different behavioural and biological phenotypes in the opioid dependence and abstinence syndromes.PostprintPeer reviewe

A Roadmap for Integrating Neuroscience into Addiction Treatment:A Consensus of the Neuroscience Interest Group of the International Society of Addiction Medicine

Although there is general consensus that altered brain structure and function underpins addictive disorders, clinicians working in addiction treatment rarely incorporate neuroscience-informed approaches into their practice. We recently launched the Neuroscience Interest Group within the International Society of Addiction Medicine (ISAMNIG) to promote initiatives to bridge this gap. This article summarises the ISAM-NIG key priorities and strategies to achieve implementation of addiction neuroscience knowledge and tools forthe assessment and treatment of substance use disorders. We cover two assessment areas: cognitive assessment and neuroimaging, and two interventional areas: cognitive training/remediation and neuromodulation, where we identify key challenges and proposed solutions. We reason that incorporating cognitive assessment into clinical settings requires the identification of constructs that predict meaningful clinical outcomes. Other requirements are the development of measures that are easily-administered, reliable and ecologically-valid. Translation of neuroimaging techniques requires the development of diagnostic and prognostic biomarkers and testing the cost-effectiveness of these biomarkers in individualised prediction algorithms for relapse prevention and treatment selection. Integration of cognitive assessments with neuroimaging can provide multilevel targets including neural, cognitive, and behavioural outcomes for neuroscience-informed interventions. Application of neuroscience-informed interventions including cognitive training/remediation and neuromodulation requires clear pathways to design interventions based on multilevel targets, additional evidence from randomised trials and subsequent clinical implementation, including evaluation of cost-effectiveness. We propose to address these challenges by promoting international collaboration between researchers and clinicians, developing harmonised protocols and data management systems, and prioritising multi-site research that focuses on improving clinical outcomes

Landscape approaches for ecosystem management in Mediterranean Islands

This book presents a series of essays, drawing on the twm concepts of ecosystem management and landscape approaches, to elucidate and reflect on the present situation and future evolution of Mediterranean islands. This publication brings together contributions from Mediterranean individuals, non-Mediterranean individuals, islanders and non-islanders there is, after all, no geographical limit on who and what we can learn from. The essays presented here each contribute a specific perspective on the future evolution of Mediterranean islands. This book presents a series of essays, drawing on the twin concepts of ecosystem management and landscape approaches, to elucidate and reflect on the present situation and future evolution of Mediterranean islands. This publication brings together contributions from Mediterranean individuals, non-Mediterranean individuals, islanders and non-islanders; there is, after all, no geographical limit on who and what we can learn from. The essays presented here each contribute a specific perspective on the future evolution of Mediterranean islands. Following this introductory chapter, the first section of the book focuses on the contributions that can be made by the discipline of landscape ecology. loannis Vogiatzakis and Geoffrey Griffiths first explain the concepts and relevance of landscape ecology, also presenting and discussing a range of applied tools that can facilitate landscape planning in Mediterranean islands. Louis F. Cassar then reviews the 'offshoot' discipline of restoration ecology, making a strong case for offsetting the environmental damage inflicted on natural ecosystems over millennia of human occupation, with constructive efforts to effectively restore and/or rehabilitate ecosystems. The two following chapters bring the socio-economic dimension into the discussion. Godfrey Baldacchino first presents two contrasting paradigms for the development of island territories, reviewing the dual influences of ecological and economic factors, and exploring ways in which the two can be brought together in successful development strategies. Gordon Cordina and Nadia Farrugia then address the demographic dimension of development, presenting a model to explain the economic costs of high population densities on islands. The third block of chapters expands on the relevance of social and cultural dynamics to the management of Mediterranean Islands. Isil Cakcï, Nur Belkayali and Ilkden Tazebay explain the evolution of the concept of a 'cultural landscape', focusing on the challenges of managing change in landscapes with strong heritage values. The chapter concludes with a case study on the Turkish island of Gökçeada (lmbros), which is experiencing major challenges in balancing the conservation of a cultural landscape on the one hand, and the management of inevitable change, on the other. Elisabeth Conrad then discusses the role of social capital in managing the landscape resources of Mediterranean islands, reviewing the potential for this intangible social fabric to facilitate or impede the sustainable evolution of island territories. The fourth section includes four chapters, each of which addresses a different aspect relevant to policy development and implementation in Mediterranean islands. Salvino Busuttil presents an essay outlining the political influences on the management of coastal landscapes, the latter so relevant to Mediterranean island territories. The essay derives from the author's professional experience in various policy-related institutions for environmental management within the Mediterranean region. Maggie Roe then reflects on issues of landscape sustainability, focusing on the neglected aspect of intelligence. She discusses ways in which landscape research, knowledge and understanding can feed directly into frameworks for 'sustainable' landscape planning. In the subsequent chapter, Adrian Phillips takes from his substantial experience with international landscape policy, reviewing the gradual emergence of international and national landscape 'tools', to draw out lessons for application in Mediterranean islands. In the final chapter of this section, Riccardo Priore and Damiano Galla present a comprehensive discussion of the European Landscape Convention, the first international instrument to focus exclusively on landscape. The authors explain the innovative character of this convention, and discuss its potential implementation in Mediterranean islands. The publication concludes with a series of case studies, highlighting specific constraints, experiences and opportunities in different Mediterranean islands. Theano Terkenli explores the landscapes of tourism in Mediterranean islands - perhaps no other industry has played such a fundamental role in shaping the evolution of Mediterranean landscapes in recent years. The author reviews the theoretical relationship between landscape and tourism across Mediterranean islands, before focusing on the specific case of the Greek Cycladic islands. In the following chapter, Alex Camilleri, Isabella Colombini and Lorenzo Chelazzi present an in-depth review of the context and challenges being faced on a number of minor Mediterranean islands, namely those of the Tuscan archipelago (Elba, Giglio, Capraia, Montecristo, Pianosa, Gorgona and Giannutri), and Comino, the latter forming part of the Maltese archipelago. The comparison between these various islands enables an appreciation of both commonalities across these islands, as well as considerations that are specific to the context of each in dividual island. JeremyBoissevain then adopts an anthropological lens to review the cautionary tale of landscape change in Malta, exploring underlying causes of landscape destruction and limited civil engagement. In the subsequent chapter, Jala Makhzoumi outlines the richness of Mediterranean islands' rural landscapes, focusing on olive landscapes in Cyprus. Her research demonstrates the economic and ecological robustness of various olive cultivation practices, and whilst warning of several threats to such sustainable regimes, she outlines strategies for reconfiguring our approach to rural heritage, in order to integrate such assets into sustainable development strategies. Finally, Stephen Morse concludes the section with an evaluation of sustainable development indicators, and the contribution that these can make towards enhancing the management of Mediterranean island territories. He illustrates his arguments with reference to the two island states of Malta and Cyprus. To conclude, in the final chapter of this publication, we review key insights emerging from the various chapters, and summarize considerations for ecosystem management and sustainable development in Mediterranean Islands. We truly hope that this publication makes some contribution towards safeguarding the "magic' of Mediterranean islands, whilst embracing their dynamic characteristics.Published under the patronage of UNESCO and with the support of the Maltese National Commission for UNESCOpeer-reviewe

Chronic heroin use disorder and the brain:current evidence and future implications

The incidence of chronic heroin use disorder, including overdose deaths, has reached epidemic proportions. Here we summarise and evaluate our knowledge of the relationship between chronic heroin use disorder and the brain through a narrative review. A broad range of areas was considered including causal mechanisms, cognitive and neurological consequences of chronic heroin use and novel neuroscience-based clinical interventions. Chronic heroin use is associated with limited or very limited evidence of impairments in memory, cognitive impulsivity, non-planning impulsivity, compulsivity and decision-making. Additionally, there is some evidence for certain neurological disorders being caused by chronic heroin use, including toxic leukoencephalopathy and neurodegeneration. However, there is insufficient evidence on whether these impairments and disorders recover after abstinence. Whilst there is a high prevalence of comorbid psychiatric disorders, there is no clear evidence that chronic heroin use per se causes depression, bipolar disorder, PTSD and/or psychosis. Despite the growing burden on society from heroin use, knowledge of the long-term effects of chronic heroin use disorder on the brain remains limited. Nevertheless, there is evidence for progress in neuroscience-based interventions being made in two areas: assessment (cognitive assessment and neuroimaging) and interventions (cognitive training/remediation and neuromodulation). Longitudinal studies are needed to unravel addiction and neurotoxic mechanisms and clarify the role of pre-existing psychiatric symptoms and cognitive impairments.PostprintPeer reviewe

Neurobehavioral consequences of chronic intrauterine opioid exposure in infants and preschool children: a systematic review and meta-analysis

&lt;b&gt;Background&lt;/b&gt;&lt;p&gt;&lt;/p&gt; It is assumed within the accumulated literature that children born of pregnant opioid dependent mothers have impaired neurobehavioral function as a consequence of chronic intrauterine opioid use.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods&lt;/b&gt;&lt;p&gt;&lt;/p&gt; Quantitative and systematic review of the literature on the consequences of chronic maternal opioid use during pregnancy on neurobehavioral function of children was conducted using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We searched Cinahl, EMBASE, PsychINFO and MEDLINE between the periods of January 1995 to January 2012.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Results&lt;/b&gt;&lt;p&gt;&lt;/p&gt; There were only 5 studies out of the 200 identified that quantitatively reported on neurobehavioral function of children after maternal opioid use during pregnancy. All 5 were case control studies with the number of exposed subjects within the studies ranging from 33–143 and 45–85 for the controls. This meta-analysis showed no significant impairments, at a non-conservative significance level of p &#60; 0.05, for cognitive, psychomotor or observed behavioural outcomes for chronic intra-uterine exposed infants and pre-school children compared to non-exposed infants and children. However, all domains suggested a trend to poor outcomes in infants/children of opioid using mothers. The magnitude of all possible effects was small according to Cohen’s benchmark criteria.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusions&lt;/b&gt;&lt;p&gt;&lt;/p&gt; Chronic intra-uterine opioid exposed infants and pre-school children experienced no significant impairment in neurobehavioral outcomes when compared to non-exposed peers, although in all domains there was a trend to poorer outcomes. The findings of this review are limited by the small number of studies analysed, the heterogenous populations and small numbers within the individual studies. Longitudinal studies are needed to determine if any neuropsychological impairments appear after the age of 5 years and to help investigate further the role of environmental risk factors on the effect of ‘core’ phenotypes